What is Logotherapy?

Introduction

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

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

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

Basic Principles

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

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

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

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

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

Discovering Meaning

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

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

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

Philosophical Basis of Logotherapy

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

Logotherapeutic Views and Treatment

Overcoming Anxiety

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

Treatment of Neurosis

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

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

Depression

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

Obsessive-Compulsive Disorder

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

Schizophrenia

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

Terminally Ill Patients

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

Forms of Treatment

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

Controversy

Authoritarianism

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

Religiousness

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

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

Recent Developments

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

On This Day … 14 June

People (Births)

  • 1864 – Alois Alzheimer, German psychiatrist and neuropathologist (d. 1915).

Alois Alzheimer

Alois Alzheimer (14 June 1864 to 19 December 1915) was a German psychiatrist and neuropathologist and a colleague of Emil Kraepelin. Alzheimer is credited with identifying the first published case of “presenile dementia”, which Kraepelin would later identify as Alzheimer’s disease.

After graduating from Wurzburg as a Doctor of Medicine in 1887, he spent five months assisting mentally ill women before he took an office in the city mental asylum in Frankfurt, the Städtische Anstalt für Irre und Epileptische (Asylum for Lunatics and Epileptics). Emil Sioli, a noted psychiatrist, was the dean of the asylum. Another neurologist, Franz Nissl, began to work in the same asylum with Alzheimer. Together, they conducted research on the pathology of the nervous system, specifically the normal and pathological anatomy of the cerebral cortex. Alzheimer was the co-founder and co-publisher of the journal Zeitschrift für die gesamte Neurologie und Psychiatrie, though he never wrote a book that he could call his own.

While at the Frankfurt asylum, Alzheimer also met Emil Kraepelin, one of the best-known German psychiatrists of the time. Kraepelin became a mentor to Alzheimer, and the two worked very closely for the next several years. When Kraepelin moved to Munich to work at the Royal Psychiatric Hospital in 1903, he invited Alzheimer to join him.

At the time, Kraepelin was doing clinical research on psychosis in senile patients; Alzheimer, on the other hand, was more interested in the lab work of senile illnesses. The two men would face many challenges involving the politics of the psychiatric community. For example, both formal and informal arrangements would be made among psychiatrists at asylums and universities to receive cadavers.

In 1904, Alzheimer completed his Habilitation at Ludwig Maximilian University of Munich, where he was appointed as a professor in 1908. Afterwards, he left Munich for the Silesian Friedrich Wilhelm University in Breslau in 1912, where he accepted a post as professor of psychiatry and director of the Neurologic and Psychiatric Institute. His health deteriorated shortly after his arrival so that he was hospitalised. Alzheimer died three years later.

Auguste Deter

In 1901, Alzheimer observed a patient at the Frankfurt asylum named Auguste Deter. The 51-year-old patient had strange behavioral symptoms, including a loss of short-term memory; she became his obsession over the coming years. Auguste Deter was a victim of the politics of the time in the psychiatric community; the Frankfurt asylum was too expensive for her husband. Herr Deter made several requests to have his wife moved to a less expensive facility, but Alzheimer intervened in these requests. Frau Deter, as she was known, remained at the Frankfurt asylum, where Alzheimer had made a deal to receive her records and brain upon her death.

On 8 April 1906, Frau Deter died, and Alzheimer had her medical records and brain brought to Munich where he was working in Kraepelin’s laboratory. With two Italian physicians, he used the staining techniques of Bielschowsky to identify amyloid plaques and neurofibrillary tangles. These brain anomalies would become identifiers of what later became known as Alzheimer’s disease.

Another hypothesis offered by Claire O’Brien was that Auguste Deter actually had a vascular dementing disease.

Findings

Alzheimer discussed his findings on the brain pathology and symptoms of presenile dementia publicly on 03 November 1906, at the Tübingen meeting of the Southwest German Psychiatrists. The attendees at this lecture seemed uninterested in what he had to say. The lecturer that followed Alzheimer was to speak on the topic of “compulsive masturbation”, which the audience was so eagerly awaiting that they sent Alzheimer away without any questions or comments on his discovery of the pathology of a type of senile dementia.

Following the lecture, Alzheimer published a short paper summarizing his lecture; in 1907 he wrote a larger paper detailing the disease and his findings. The disease would not become known as Alzheimer’s disease until 1910, when Kraepelin named it so in the chapter on “Presenile and Senile Dementia” in the 8th edition of his Handbook of Psychiatry. By 1911, his description of the disease was being used by European physicians to diagnose patients in the US.

Contemporaries

American Solomon Carter Fuller gave a report similar to that of Alzheimer at a lecture five months before Alzheimer. Oskar Fischer was a fellow German psychiatrist, 12 years Alzheimer’s junior, who reported 12 cases of senile dementia in 1907 around the time that Alzheimer published his short paper summarizing his lecture.

Alzheimer and Fischer had different interpretations of the disease, but due to Alzheimer’s short life, they never had the opportunity to meet and discuss their ideas.

Among the doctors trained by Alois Alzheimer and Emil Kraepelin at München in the beginning of the XXth century were the Spanish neuropathologists Nicolás Achúcarro and Gonzalo Rodríguez Lafora, two distinguished disciples of Santiago Ramón y Cajal and members of the Spanish Neurological School. Alzheimer recommended the young and brilliant Nicolás Achúcarro to organise the neuropathological service at the Government Hospital for the Insane, at Washington D.C. (current, NIH), and after two years of work, he was substituted by Gonzalo Rodríguez Lafora.

Other Interests

Alzheimer was known for having a variety of medical interests including vascular diseases of the brain, early dementia, brain tumours, forensic psychiatry and epilepsy. Alzheimer was a leading specialist in histopathology in Europe. His colleagues knew him to be a dedicated professor and cigar smoker.

On This Day … 13 June

People (Births)

  • 1809 – Heinrich Hoffmann, German psychiatrist and author (d. 1894).
  • 1894 – Leo Kanner, Ukrainian-American psychiatrist and physician (d. 1981).
  • 1931 – Irvin D. Yalom, American psychotherapist and academic.

Heinrich Hoffmann

Heinrich Hoffmann (13 June 1809 to 20 September 1894) was a German psychiatrist, who also wrote some short works including Der Struwwelpeter, an illustrated book portraying children misbehaving.

Hoffmann worked for a pauper’s clinic and had a private practice. He also taught anatomy at the Senckenberg Foundation. None of this paid very well, and when the Frankfurt lunatic asylum’s previous doctor (who was a friend of his) retired in 1851, he was eager to take the post even though he had no expertise in psychiatry. This changed quickly, as his later competent publications in the field show. Hoffmann portrays himself as a caring, humane psychiatrist, who strove to be the sunshine in the life of his miserable patients. His gregarious personality may well have been popular with many of them. His statistical compilations show that up to 40% of the people with acute cases of what would today be called schizophrenia were discharged after a few weeks or months and stayed in remission for years and perhaps permanently. Always a skeptic, Hoffmann voices doubts whether this was due to any therapy he may have given them. Much of his energy from 1851 onwards went into campaigning for a new, modern asylum building with gardens in the city’s green belt. He was successful and the new clinic was built at the site of today’s Frankfurt University’s Humanities campus (The original building was demolished in the 1920s).

Leo Kanner

Leo Kanner (13 June 1894 to 03 April 1981) was an Ukrainian American psychiatrist, physician, and social activist best known for his work related to autism. Before working at the Henry Phipps Psychiatric Clinic at the Johns Hopkins Hospital, Kanner practiced as a physician in Germany and in South Dakota. In 1943, Kanner published his landmark paper Autistic Disturbances of Affective Contact, describing 11 children who were highly intelligent but displayed “a powerful desire for aloneness” and “an obsessive insistence on persistent sameness.” He named their condition “early infantile autism,” which is now known as autism spectrum disorder. Kanner was in charge of developing the first child psychiatry clinic in the United States and later served as the Chief of Child Psychiatry at the Johns Hopkins Hospital. He is one of the co-founders of The Children’s Guild, a non-profit organisation serving children, families and child-serving organisations throughout Maryland and Washington, D.C., and dedicated to “Transforming how America Cares for and Educates its Children and Youth.” He is widely considered one of the most influential American psychiatrists of the 20th century.

Irvin D. Yalon

Irvin David Yalom (born 13 June 1931) is an American existential psychiatrist who is emeritus professor of psychiatry at Stanford University, as well as author of both fiction and nonfiction.

After graduating with a BA from George Washington University in 1952 and a Doctor of Medicine from Boston University School of Medicine in 1956 he went on to complete his internship at Mount Sinai Hospital in New York and his residency at the Phipps Clinic of Johns Hopkins Hospital in Baltimore and completed his training in 1960. After two years of Army service at Tripler General Hospital in Honolulu, Yalom began his academic career at Stanford University. He was appointed to the faculty in 1963 and promoted over the following years, being granted tenure in 1968. Soon after this period he made some of his most lasting contributions by teaching about group psychotherapy and developing his model of existential psychotherapy.

His writing on existential psychology centres on what he refers to as the four “givens” of the human condition: isolation, meaninglessness, mortality and freedom, and discusses ways in which the human person can respond to these concerns either in a functional or dysfunctional fashion.

In 1970, Yalom published The Theory and Practice of Group Psychotherapy, speaking about the research literature around group psychotherapy and the social psychology of small group behavior. This work explores how individuals function in a group context, and how members of group therapy gain from his participation group.

In addition to his scholarly, non-fiction writing, Yalom has produced a number of novels and also experimented with writing techniques. In Every Day Gets a Little Closer Yalom invited a patient to co-write about the experience of therapy. The book has two distinct voices which are looking at the same experience in alternating sections. Yalom’s works have been used as collegiate textbooks and standard reading for psychology students. His new and unique view of the patient/client relationship has been added to curriculum in psychology programs at such schools as John Jay College of Criminal Justice in New York City.

Yalom has continued to maintain a part-time private practice and has authored a number of video documentaries on therapeutic techniques. Yalom is also featured in the 2003 documentary Flight from Death, a film that investigates the relationship of human violence to fear of death, as related to subconscious influences. The Irvin D. Yalom Institute of Psychotherapy, which he co-directs with Professor Ruthellen Josselson, works to advance Yalom’s approach to psychotherapy. This unique combination of integrating more philosophy into the psychotherapy can be considered as psychosophy.

He was married to author and historian Marilyn Yalom, who died in November, 2019. Their four children are: Eve, a gynaecologist, Reid, a photographer, Victor, a psychologist and entrepreneur and Ben, a theatre director.

What is Analytical Psychology?

Introduction

Analytical psychology (German: Analytische Psychologie, sometimes translated as analytic psychology and referred to as Jungian analysis) is a term coined by Carl Jung, a Swiss psychiatrist, to describe research into his new “empirical science” of the psyche.

It was designed to distinguish it from Freud’s psychoanalytic theories as their seven-year collaboration on psychoanalysis was drawing to an end between 1912 and 1913. The evolution of his science is contained in his monumental opus, the Collected Works, written over sixty years of his lifetime.

The history of analytical psychology is intimately linked with the biography of Jung. At the start, it was known as the “Zurich school”, whose chief figures were Eugen Bleuler, Franz Riklin, Alphonse Maeder and Jung, all centred in the Burghölzli hospital in Zurich. It was initially a theory concerning psychological complexes until Jung, upon breaking with Sigmund Freud, turned it into a generalised method of investigating archetypes and the unconscious, as well as into a specialised psychotherapy.

Analytical psychology, or “complex psychology”, from the German: Komplexe Psychologie, is the foundation of many developments in the study and practice of Psychology as of other disciplines. The followers of Jung are many, and some of them are members of national societies in diverse countries around the world. They collaborate professionally on an international level through the International Association of Analytical Psychologists (IAAP) and the International Association for Jungian Studies (IAJS). Jung’s propositions have given rise to a rich and multidisciplinary literature in numerous languages.

Among widely used concepts owed specifically to Analytical psychology are: anima and animus, archetypes, the collective unconscious, complexes, extraversion and introversion, individuation, the Self, the shadow and synchronicity. The Myers–Briggs Type Indicator (MBTI) is based on another of Jung’s theories on psychological types. A lesser known idea was Jung’s notion of the Psychoid to denote a hypothesised immanent plane beyond consciousness, distinct from the collective unconscious, and a potential locus of synchronicity.

The approximately “three schools” of post-Jungian analytical psychology that are current, the classical, archetypal and developmental, can be said to correspond to the developing yet overlapping aspects of Jung’s lifelong explorations, even if he expressly did not want to start a school of “Jungians”. Hence as Jung proceeded from a clinical practice which was mainly traditionally science-based and steeped in rationalist philosophy, anthropology and ethnography, his enquiring mind simultaneously took him into more esoteric spheres such as alchemy, astrology, gnosticism, metaphysics, myth and the paranormal, without ever abandoning his allegiance to science as his long-lasting collaboration with Wolfgang Pauli attests. His wide-ranging progression suggests to some commentators that, over time, his analytical psychotherapy, informed by his intuition and teleological investigations, became more of an “art”.

The findings of Jungian analysis and the application of analytical psychology to contemporary preoccupations such as social and family relationships, dreams and nightmares, work-life balance, architecture and urban planning, politics and economics, conflict and warfare, and climate change are illustrated in a growing number of publications and films.

Background

Jung began his career as a psychiatrist in Zürich, Switzerland. Already employed at the Burghölzli hospital in 1901, in his academic dissertation for the medical faculty of the University of Zurich he took the risk of using his experiments on somnambulism and the visions of his mediumistic cousin, Helly Preiswerk. The work was entitled, “On the Psychology and Pathology of So-Called Occult Phenomena”. It was accepted but caused great upset among his mother’s family. Under the direction of psychiatrist Eugen Bleuler, he also conducted research with his colleagues using a galvanometer to evaluate the emotional sensitivities of patients to lists of words during word association. Jung has left a description of his use of the device in treatment. His research earned him a worldwide reputation and numerous honours, including Honorary Doctorates from Clark and Fordham Universities in 1909 and 1910 respectively. Other honours followed later.

Although they began corresponding a year earlier, in 1907 Jung travelled to meet Sigmund Freud in Vienna, Austria. At that stage, Jung, aged thirty-two, had a much greater international renown than the forty-nine year old neurologist. For a further six years, the two scholars worked and travelled to the United States together. In 1911, they founded the International Psychoanalytical Association, of which Jung was the first president. However, early in the collaboration, Jung had already observed that Freud would not tolerate ideas that were different from his own.

Unlike most modern psychologists, Jung did not believe in restricting himself to the scientific method as a means to understanding the human psyche. He saw dreams, myths, coincidence and folklore as empirical evidence to further understanding and meaning. So although the unconscious cannot be studied by using direct methods, it acts as a useful working hypothesis, according to Jung. As he said, “The beauty about the unconscious is that it is really unconscious.” Hence, the unconscious is ‘untouchable’ by experimental researches, or indeed any possible kind of scientific or philosophical reach, precisely because it is unconscious.

The Break with Freud

It was the publication of a book by Jung which provoked the break with psychoanalysis and led to the founding of analytical psychology. In 1912 Jung met “Miss Miller”, brought to his notice by the work of Théodore Flournoy and whose case gave further substance to his theory of the collective unconscious. The study of her visions supplied the material which would go on to furnish his reasoning which he developed in Psychology of the Unconscious (Wandlungen und Symbole der Libido) (re-published as Symbols of Transformation in 1952) (C.W. Vol. 5). At this, Freud muttered about “heresy”. It was the second part of the work that brought the divergence to light. Freud mentioned to Ernest Jones that it was on page 174 of the original German edition, that Jung, according to him, had “lost his way”. It is the extract where Jung enlarged on his conception of the libido. The sanction was immediate: Jung was officially banned from the Vienna psychoanalytic circle from August 1912. From that date the psychoanalytic movement split into two obediences, with Freud’s partisans on one side, Karl Abraham being delegated to write a critical notice about Jung, and with Ernest Jones as defender of Freudian orthodoxy; while on the other side, were Jung’s partisans, including Leonhard Seif, Franz Riklin, Johan van Ophuijsen and Alphonse Maeder.

Jung’s innovative ideas with a new formulation of psychology and lack of contrition sealed the end of the Jung-Freud friendship in 1913. From then, the two scholars worked independently on personality development: Jung had already termed his approach analytical psychology (1912), while the approach Freud had founded is referred to as the Psychoanalytic School, (psychoanalytische Schule).

Jung’s postulated unconscious was quite different from the model proposed by Freud, despite the great influence that the founder of psychoanalysis had had on him. In particular, tensions manifested between him and Freud because of various disagreements, including those concerning the nature of the libido. Jung de-emphasized the importance of sexual development as an instinctual drive and focused on the collective unconscious: the part of the unconscious that contains memories and ideas which Jung believed were inherited from generations of ancestors. While he accepted that libido was an important source for personal growth, unlike Freud, Jung did not consider that libido alone was responsible for the formation of the core personality. Due to the particular hardships Jung had endured growing up, he believed his personal development and that of everyone was influenced by factors unrelated to sexuality.

The overarching aim in life, according to Jungian psychology, is the fullest possible actualisation of the “Self” through individuation. Jung defines the “self” as “not only the centre but also the whole circumference which embraces both conscious and unconscious; it is the centre of this totality, just as the ego is the centre of the conscious mind”. Central to this process of individuation is the individual’s continual encounter with the elements of the psyche by bringing them into consciousness. People experience the unconscious through symbols encountered in all aspects of life: in dreams, art, religion, and the symbolic dramas enacted in relationships and life pursuits. Essential to the process is the merging of the individual’s consciousness with the collective unconscious through a huge range of symbols. By bringing conscious awareness to bear on what is unconscious, such elements can be integrated with consciousness when they “surface”. To proceed with the individuation process, individuals need to be open to the parts of themselves beyond their own ego, which is the “organ” of consciousness. In a famous dictum, Jung said, “the Self, like the unconscious is an a priori existent out of which the ego evolves. It is … an unconscious prefiguration of the ego. It is not I who create myself, rather I happen to myself’.

It follows that the aim of (Jungian) psychotherapy is to assist the individual to establish a healthy relationship with the unconscious so that it is neither excessively out of balance in relation to it, as in neurosis, a state that can result in depression, anxiety, and personality disorders or so flooded by it that it risks psychosis resulting in mental breakdown. One method Jung applied to his patients between 1913 and 1916 was active imagination, a way of encouraging them to give themselves over to a form of meditation to release apparently random images from the mind in order to bridge unconscious contents into awareness.

“Neurosis” in Jung’s view results from the build up of psychological defences the individual unconsciously musters in an effort to cope with perceived attacks from the outside world, a process he called a “complex”, although complexes are not merely defensive in character. The psyche is a self-regulating adaptive system. People are energetic systems, and if the energy is blocked, the psyche becomes sick. If adaptation is thwarted, the psychic energy stops flowing and becomes rigid. This process manifests in neurosis and psychosis. Jung proposed that this occurs through maladaptation of one’s internal realities to external ones. The principles of adaptation, projection, and compensation are central processes in Jung’s view of psyche’s attempts to adapt.

Innovations of Jungian Analysis

Philosophical and Epistemological Foundations

Philosophy

Jung was an adept principally of the American philosopher William James, founder of pragmatism, whom he met during his trip to the United States in 1909. He also encountered other figures associated with James, such as John Dewey and the anthropologist, Franz Boas. Pragmatism was Jung’s favoured route to base his psychology on a sound scientific basis according to historian Sonu Shamdasani. His theories consist of observations of phenomena, and according to Jung it is phenomenology. In his view psychologism was suspect.

Displacement into the conceptual deprives experience of its substance and the possibility of being simply named.

Throughout his writings, Jung sees in empirical observation not only a precondition of an objective method but also respect for an ethical code which should guide the psychologist, as he stated in a letter to Joseph Goldbrunner:

I consider it a moral obligation not to make assertions about things one cannot see or whose existence cannot be proved, and I consider it an abuse of epistemological power to do so regardless. These rules apply to all experimental science. Other rules apply to metaphysics. I regard myself as answerable to the rules of experimental science. As a result nowhere in my work are there any metaphysical assertions nor – nota bene – any negations of a metaphysical nature.

According to the Italo-French psychoanalyst Luigi Aurigemma, Jung’s reasoning is also marked by Immanuel Kant, and more generally by German rationalist philosophy. His lectures are evidence of his assimilation of Kantian thought, especially the Critique of Pure Reason and Critique of Practical Reason. Aurigemma caracterises Jung’s thinking as “epistemological relativism” because it does not postulate any belief in the metaphysical. In fact, Jung uses Kant’s teleology to bridle his thinking and to guard himself from straying into any metaphysical excursions. On the other hand, for French historian of psychology, Françoise Parot, contrary to the alleged rationalist vein, Jung is “heir” to mystics, (Meister Eckhart, Hildegard of Bingen, or Augustine of Hippo) and to the romantics be they scientists, such as Carl Gustav Carus or Gotthilf Heinrich von Schubert in particular, or to philosophers and writers, along the lines of Nietzsche, Goethe, and Schopenhauer, in the way he conceptualised the unconscious in particular. Whereas his typology is profoundly dependent on Carl Spitteler.

Scientific Heritage

As a trained psychiatrist, Jung had a grounding in the state of science in his day. He regularly refers to the experimental psychology of Wilhelm Wundt. His Word Association Test designed with Franz Riklin is actually the direct application of Wundt’s theory. Notwithstanding the great debt of analytical psychology to Sigmund Freud, Jung borrowed concepts from other theories of his time. For instance, the expression “abaissement du niveau mental” comes directly from the French psychologist Pierre Janet whose courses Jung attended during his studies in France, during 1901. Jung had always acknowledged how much Janet had influenced his career.

Jung’s use of the concept of “participation mystique” is owed to the French ethnologist Lucien Lévy-Bruhl:

What Rousseau describes is nothing other than the primitive collective mentality which Lucien Lévy-Bruhl has brilliantly called “participation mystique”

which he uses to illustrate the surprising fact, to him, that some native peoples can experience relations that defy logic, as for instance in the case of the South American tribe, whom he met during his travels, where the men pretended they were scarlet aras birds. Finally, his use of the English expression, “pattern of behaviour”, which is synonymous with the term archetype, is drawn from British studies in ethology.

The principal contribution to analytical psychology, nevertheless, remains that of Freud’s psychoanalysis, from which Jung took a number of concepts, especially the method of inquiring into the unconscious through free association. Individual analysts’ thinking was also integrated into his project, among whom are Sándor Ferenczi (Jung refers to his notion of “affect”) or Ludwig Binswanger and his Daseinsanalyse [de], (Daseinsanalysis). Jung affirms also Freud’s contribution to our knowledge of the psyche as being, without doubt, of the highest importance. It reveals penetrating information about the dark corners of the soul and of the human personality, which is of the same order as Nietzsche’s On the Genealogy of Morality (1887). In this context, Freud was, according to Jung, one of the great cultural critics of the XIXth century.

Divergences from Psychoanalysis

Jungian Analysis, as is psychoanalysis, is a method to access, experience and integrate unconscious material into awareness. It is a search for the meaning of behaviours, feelings and events. Many are the channels to extend knowledge of the self: the analysis of dreams is one important avenue. Others may include expressing feelings about and through art, poetry or other expressions of creativity, the examination of conflicts and repeating patterns in a person’s life. A comprehensive description of the process of dream interpretation is complex, in that it is highly specific to the person who undertakes it. Most succinctly it relies on the associations which the particular dream symbols suggest to the dreamer, which at times may be deemed “archetypal” in so far as they are supposed common to many people throughout history. Examples could be a hero, an old man or woman, situations of pursuit, flying or falling.

Whereas (Freudian) psychoanalysis relies entirely on the development of the transference in the analysand (the person under treatment) to the analyst, Jung initially used the transference and later concentrated more on a dialectical and didactic approach to the symbolic and archetypal material presented by the patient. Moreover his attitude towards patients departed from what he had observed in Freud’s method. Anthony Stevens has explained it thus:

Though [Jung’s] initial formulations arose mainly out of his own creative illness, they were also a conscious reaction against the stereotype of the classical Freudian analyst, sitting silent and aloof behind the couch, occasionally emitting ex cathedra pronouncements and interpretations, while remaining totally uninvolved in the patient’s guilt, anguish, and need for reassurance and support. Instead, Jung offered the radical proposal that analysis is a dialectical procedure, a two-way exchange between two people, who are equally involved. Although it was a revolutionary idea when he first suggested it, it is a model which has influenced psychotherapists of most schools, though many seem not to realise that it originated with Jung.

In place of Freud’s “surgical detachment”, Jung demonstrated a more relaxed and warmer welcome in the consulting room. He remained aware nonetheless that exposure to a patient’s unconscious contents always posed a certain risk of contagion (he calls it “psychic infection”) to the analyst, as experienced in the countertransference. The process of contemporary Jungian analysis depends on the type of “school of analytical psychology” to which the therapist adheres, (see below). The “Zurich School” would reflect the approach Jung himself taught, while those influenced by Michael Fordham and associates in London, would be significantly closer to a Kleinian approach and therefore, concerned with analysis of the transference and countertransference as indicators of repressed material along with the attendant symbols and patterns.

Dream Work

Jung’s preoccupation with dreams can be dated from 1902. It was only after the break with Freud that he published in 1916 his “Psychology of the Unconscious” where he elaborated his view of dreams, which contrasts sharply with Freud’s conceptualisation. While he agrees that dreams are a highway into the unconscious, he enlarges on their functions further than psychoanalysis did. One of the salient differences is the compensatory function they perform by reinstating psychic equilibrium in respect of judgements made during waking life: thus a man consumed by ambition and arrogance may, for example, dream about himself as small and vulnerable person.

According to Jung, this demonstrates that the man’s attitude is excessively self-assured and thereby refuses to integrate the inferior aspects of his personality, which are denied by his defensive arrogance. Jung calls this a compensation mechanism, necessary for the maintenance of a healthy mental balance. Shortly before his death in 1961, he wrote:

In order to secure mental and even physiological stability, it is necessary that the conscious and unconscious should be integrated one with the other. This is so that they evolve in parallel. (Pour sauvegarder la stabilité mentale, et même physiologique, il faut que la conscience et l’inconscient soient intégralement reliés, afin d’évoluer parallèlement).

Unconscious material is expressed in images through the deployment of symbolism which, in Jungian terms, means it has an affective role (in that it can sometimes give rise to a numinous feeling, when associated with an archetypal force) and an intellectual role. Some dreams are personal to the dreamer, others may be collective in origin or “transpersonal” in so far as they relate to existential events. They can be taken to express phases of the individuation process (see below) and may be inspired by literature, art, alchemy or mythology. Analytical psychology is recognised for its historical and geographical study of myths as a means to deconstruct, with the aid of symbols, the unconscious manifestations of the psyche. Myths are said to represent directly the elements and phenomena arising from the collective unconscious and though they may be subject to alteration in their detail through time, their significance remains similar. While Jung relies predominantly on christian or on Western pagan mythology (Ancient Greece and Rome), he holds that the unconscious is driven by mythologies derived from all cultures. He evinced an interest in Hinduism, in Zoroastrianism and Taoism, which all share fundamental images reflected in the psyche. Thus analytical psychology focusses on meaning, based on the hypothesis that human beings are potentially in constant touch with universal and symbolic aspects common to humankind. In the words of André Nataf:

Jung opens psychoanalysis to a dimension currently obscured by the prevailing scientism: spirituality. His contribution, though questionable in certain respects, remains unique. His explorations of the unconscious carried out both as a scientist and a poet, indicate that it is structured as a language but one which is in a mythical mode. (Jung ouvre la psychanalyse à une dimension cachée par le scientisme ambiant : la spiritualité. Son apport, quoique contestable sur certains points, reste unique. Explorant l’inconscient en scientifique et poète, il montre que celui-ci se structure non comme une langue mais sur le mode du mythe).

Principal Concepts

In analytical psychology two distinct types of psychological process may be identified: that deriving from the individual, characterised as “personal”, belonging to a subjective psyche, and that deriving from the collective, linked to the structure of an objective psyche, which may be termed “transpersonal”. These processes are both said to be archetypal. Some of these processes are regarded as specifically linked to consciousness, such as the animus or anima, the persona or the shadow. Others pertain more to the collective sphere. Jung tended to personify the anima and animus as they are, according to him, always attached to a person and represent an aspect of his or her psyche.

Anima and Animus

Jung identified the archetypal anima as being the unconscious feminine component of men and the archetypal animus as the unconscious masculine component in women. These are shaped by the contents of the collective unconscious, by others, and by the larger society. However, many modern-day Jungian practitioners do not ascribe to a literal definition, citing that the Jungian concept points to every person having both an anima and an animus. Jung considered, for instance, an “animus of the anima” in men, in his work Aion and in an interview in which he says:

“Yes, if a man realizes the animus of his anima, then the animus is a substitute for the old wise man. You see, his ego is in relation to the unconscious, and the unconscious is personified by a female figure, the anima. But in the unconscious is also a masculine figure, the wise old man. And that figure is in connection with the anima as her animus, because she is a woman. So, one could say the wise old man was in exactly the same position as the animus to a woman.”

Jung stated that the anima and animus act as guides to the unconscious unified Self, and that forming an awareness and a connection with the anima or animus is one of the most difficult and rewarding steps in psychological growth. Jung reported that he identified his anima as she spoke to him, as an inner voice, unexpectedly one day.

In cases where the anima or animus complexes are ignored, they vie for attention by projecting itself on others. This explains, according to Jung, why we are sometimes immediately attracted to certain strangers: we see our anima or animus in them. Love at first sight is an example of anima and animus projection. Moreover, people who strongly identify with their gender role (e.g. a man who acts aggressively and never cries) have not actively recognised or engaged their anima or animus.

Jung attributes human rational thought to be the male nature, while the irrational aspect is considered to be natural female (rational being defined as involving judgment, irrational being defined as involving perceptions). Consequently, irrational moods are the progenies of the male anima shadow and irrational opinions of the female animus shadow.

Archetypes

The use of archetypes in psychology was advanced by Jung in an essay entitled “Instinct and the Unconscious” in 1919. The first element in Greek ‘arche’ signifies ‘beginning, origin, cause, primal source principle’, by extension it can signify ‘position of a leader, supreme rule and government’. The second element ‘type’ means ‘blow or what is produced by a blow, the imprint of a coin …form, image, prototype, model, order, and norm’, …in the figurative, modern sense, ‘pattern underlying form, primordial form’. In his psychological framework, archetypes are innate, universal or personal prototypes for ideas and may be used to interpret observations. The method he favoured was hermeneutics which was central in his practice of psychology from the start. He made explicit references to hermeneutics in the Collected Works and during his theoretical development of the notion of archetypes. Although he lacks consistency in his formulations, his theoretical development of archetypes is rich in hermeneutic implications. As noted by Smythe and Baydala (2012):

his notion of the archetype as such can be understood hermeneutically as a form of non-conceptual background understanding.

A group of memories and attitudes associated with an archetype can become a complex, e.g. a mother complex may be associated with a particular mother archetype. Jung treated the archetypes as psychological organs, analogous to physical ones in that both are morphological givens which probably arose through evolution.

Archetypes have been regarded as collective as well as individual, and identifiable in a variety of creative ways. As an example, in his book Memories, Dreams, Reflections, Jung states that he began to see and talk to a manifestation of anima and that she taught him how to interpret dreams. As soon as he could interpret on his own, Jung said that she ceased talking to him because she was no longer needed. However, the essentialism inherent in archetypal theory in general and concerning the anima, in particular, has called for a re‐evaluation of Jung’s theory in terms of emergence theory. This would emphasise the role of symbols in the construction of affect in the midst of collective human action. In such a reconfiguration, the visceral energy of a numinous experience can be retained while the problematic theory of archetypes has outlived its usefulness.

Collective Unconscious

Jung’s concept of the collective unconscious has undergone re-interpretation over time. The term “collective unconscious” first appeared in Jung’s 1916 essay, “The Structure of the Unconscious”. This essay distinguishes between the “personal”, Freudian unconscious, filled with fantasies (e.g. sexual) and repressed images, and the “collective” unconscious encompassing the soul of humanity at large.

In “The Significance of Constitution and Heredity in Psychology” (November 1929), Jung wrote:

And the essential thing, psychologically, is that in dreams, fantasies, and other exceptional states of mind the most far-fetched mythological motifs and symbols can appear autochthonously at any time, often, apparently, as the result of particular influences, traditions, and excitations working on the individual, but more often without any sign of them. These “primordial images” or “archetypes,” as I have called them, belong to the basic stock of the unconscious psyche and cannot be explained as personal acquisitions. Together they make up that psychic stratum which has been called the collective unconscious. The existence of the collective unconscious means that individual consciousness is anything but a tabula rasa and is not immune to predetermining influences. On the contrary, it is in the highest degree influenced by inherited presuppositions, quite apart from the unavoidable influences exerted upon it by the environment. The collective unconscious comprises in itself the psychic life of our ancestors right back to the earliest beginnings. It is the matrix of all conscious psychic occurrences, and hence it exerts an influence that compromises the freedom of consciousness in the highest degree, since it is continually striving to lead all conscious processes back into the old paths.

Given that in his day he lacked the advances of complexity theory and especially complex adaptive systems (CAS), it has been argued that his vision of archetypes as a stratum in the collective unconscious, corresponds to nodal patterns in the collective unconscious which go on to shape the characteristic patterns of human imagination and experience and in that sense, “seems a remarkable, intuitive articulation of the CAS model”.

Individuation

Individuation is a complex process that involves going through different stages of growing awareness through the progressive confrontation and integration of personal unconscious elements. This is the central concept of analytical psychology first introduced in 1916. It is the objective of Jungian psychotherapy to the extent that it enables the realisation of the Self. As Jung stated:

The aim of individuation is nothing less than to divest the self of the false wrappings of the persona, on the one hand and the suggestive power of primordial images on the other.

Jung started experimenting with individuation after his split with Freud as he confronted what was described as eruptions from the collective unconscious driven by a contemporary malaise of spiritual alienation. According to Jung, individuation means becoming an individual and implies becoming one’s own self. Unlike individuality, which emphasizes some supposed peculiarity, Jung described individuation as a better and more complete fulfilment of the collective qualities of the human being. In his experience, Jung explained that individuation helped him, “from the therapeutic point of view, to find the particular images that lie behind emotions”.

Individuation is from the first what the analysand must undergo, in order to integrate the other elements of the psyche. This pursuit of wholeness aims to establish the Self, which include both the rational conscious mind of the ego and the irrational contents of the unconscious, as the new personality centre. Prior to individuation, the analysand is carefully assessed to determine if the ego is strong enough to take the intensity of this process. The elements to be integrated include the persona which acts as the representative of the person in her/his role in society, the shadow which contains all that is personally unknown and what the person considers morally reprehensible and, the anima or the animus, which respectively carry their feminine and masculine values. For Jung many unconscious conflicts at the root of neurosis are caused by the difficulty to accept that such a dynamic can unbalance the subject from his habitual position and confronts her/him with aspects of the self they were accustomed to ignore. Once individuation is completed the ego is no longer at the centre of the personality. The process, however, does not lead to a complete self-realisation and that individuation can never be a fixed state due to the unfathomable nature of the depths of the collective unconscious.

Shadow

The shadow is an unconscious complex defined as the repressed, suppressed or disowned qualities of the conscious self. According to Jung, the human being deals with the reality of the shadow in four ways: denial, projection, integration and/or transmutation. Jung himself asserted that “the result of the Freudian method of elucidation is a minute elaboration of man’s shadow-side unexampled in any previous age.” According to analytical psychology, a person’s shadow may have both constructive and destructive aspects. In its more destructive aspects, the shadow can represent those things people do not accept about themselves. For instance, the shadow of someone who identifies as being kind may be harsh or unkind. Conversely, the shadow of a person who perceives himself to be brutal may be gentle. In its more constructive aspects, a person’s shadow may represent hidden positive qualities. This has been referred to as the “gold in the shadow”. Jung emphasized the importance of being aware of shadow material and incorporating it into conscious awareness in order to avoid projecting shadow qualities on others.

The shadow in dreams is often represented by dark figures of the same gender as the dreamer.

The shadow may also concern great figures in the history of human thought or even spiritual masters, who became great because of their shadows or because of their ability to live their shadows (namely, their unconscious faults) in full without repressing them.

Persona

Just like the anima and animus, the persona (derived from the Greek term for a mask, as would have been worn by actors) is another key concept in analytical psychology. It is the part of the personality which manages an individual’s relations with society in the outside world and works the same way for both sexes.

The persona … is the individual’s system of adaptation to, or the manner assumed in dealing with the world. Every calling or profession, for example, has its own characteristic persona […] Only the danger is that (people) become identical with their personas: thus the professor with his textbook, the tenor with his voice. One could say with little exaggeration, that the persona is that which in reality one is not, but which oneself as well as others think one is.

The persona, which is at the heart of the psyche, is contrary to the shadow which is actually the true personality but denied by the self. The conscious self identifies primarily with the persona during development in childhood as the individual develops a psychological framework for dealing with others. Identifications with diplomas, social roles, with honours and awards, with a career, all contribute to the apparent constitution of the persona and which do not lead to knowledge of the self. For Jung, the persona has nothing real about it. It can only be a compromise between the individual and society, yielding an illusion of individuality. Individuation consists, in the first instance, of discarding the individual’s mask, but not too quickly as often, it is all the patient has as a means of identification. The persona is implicated in a number symptoms such as compulsive disorders, phobias, shifting moods, and addictions, among others.

Psychological Types

Analytical psychology distinguishes several psychological types or temperaments.

  • Extravert.
  • Introvert.

According to Jung, the psyche is an apparatus for adaptation and orientation, and consists of a number of different psychic functions. Among these he distinguishes four basic functions:

  • Sensation: Perception by means of the sense organs.
  • Intuition: Perceiving in unconscious way or perception of unconscious contents.
  • Thinking: Function of intellectual cognition; the forming of logical conclusions.
  • Feeling: Function of subjective estimation.

Thinking and feeling functions are rational, while the sensation and intuition functions are irrational.

Note: There is ambiguity in the term ‘rational’ that Carl Jung ascribed to the thinking/feeling functions. Both thinking and feeling irrespective of orientation (i.e. introverted/extroverted) employ/utilise/are directed by in loose terminology an underlying ‘logical’ IF-THEN construct/process (as in IF X THEN Y) in order to form judgements. This underlying construct/process is not directly observable in normal states of consciousness especially when engaged in thoughts/feelings. It can be cognised merely as a concept/abstraction during thoughtful reflection. Sensation and intuition are ‘irrational’ functions simply because they do not employ the above-mentioned underlying logical construct/process.

Complexes

Early in Jung’s career he coined the term and described the concept of the “complex”. Jung claims to have discovered the concept during his free association and galvanic skin response experiments. Freud obviously took up this concept in his Oedipus complex amongst others. Jung seemed to see complexes as quite autonomous parts of psychological life. It is almost as if Jung were describing separate personalities within what is considered a single individual, but to equate Jung’s use of complexes with something along the lines of multiple personality disorder would be a step out of bounds.

Jung saw an archetype as always being the central organising structure of a complex. For instance, in a “negative mother complex,” the archetype of the “negative mother” would be seen to be central to the identity of that complex. This is to say, our psychological lives are patterned on common human experiences. Jung saw the Ego (which Freud wrote about in German literally as the “I”, one’s conscious experience of oneself) as a complex. If the “I” is a complex, what might be the archetype that structures it? Jung, and many Jungians, might say “the hero,” one who separates from the community to ultimately carry the community further.

Synchronicity

Carl Jung first officially used the term synchronicity during a conference held in memory of his sinologist friend, Richard Wilhelm in 1930. It was part of his explanation of the modus operandi of the I Ching. The second reference was made in 1935 in his Tavistock Lectures. For an overview of the origins of the concept, see Joseph Cambray: “Synchronicity as emergence”. It was used to denote the simultaneous occurrence of two events with no causal physical connection, but whose association evokes a meaning for the person experiencing or observing it. The often cited example of the phenomenon is Jung’s own account of a beetle (the common rose-chafer, Cetonia aurata) flying into his consulting room directly following on from his patient telling him a dream featuring a golden scarab. The concept only makes sense psychologically and cannot be reduced to a verified or scientific fact. For Jung it constitutes a working hypothesis which has subsequently given rise to many ambiguities.

I chose this term because the simultaneous occurrence of two meaningfully but not causally connected events seemed to me an essential criterion. I am therefore using the general concept of synchronicity in the special sense of a coincidence in time of two or more causally unrelated events which have the same or a similar meaning, in contrast to synchronism, which simply means the simultaneous occurrence of two events. Synchronicity therefore means the simultaneous occurrence of a certain psychic state with one or more external events which appear as meaningful parallels to the momentary subjective state -and, in certain cases, vice versa.

According to Jung, an archetype which has been constellated in the psyche can, under certain circumstances, transgress the boundary between substance and psyche.

Jung had studied such phenomena with the physicist and Nobel Prize winner, Wolfgang Pauli, who did not always agree with Jung, and with whom he carried on an extensive correspondence, enriched by the contributions of both specialists in their own fields. Pauli had given a series of lectures to the C.G. Jung Institute, Zürich whose member and patron he had been since 1947. It gave rise to a joint essay: Synchronicity, an a-causal principle (1952) The two men saw in the idea of synchronicity a potential way of explaining a particular relationship between “incontrovertible facts”, whose occurrence is tied to unconscious and archetypal manifestations:

The psyche and matter are ordered according to principles which are common, neutral, and incontrovertible.

Borrowing the notion from Arthur Schopenhauer, Jung calls it Unus mundus, a state where neither matter nor the psyche are distinguishable. whereas for Pauli it was a limiting concept, in two senses, in that it is at once scientific and symbolic. According to him, the phenomenon is dependent on the observer. Nevertheless, both men were in accord that there existed the possibility of a conjunction between physics and psychology. Jung wrote in a letter to Pauli:

These researches (Jung’s research into alchemy), have shown me that modern physics can symbolically represent psychological processes down to the minutest detail.

Marie-Louise von Franz also had a lengthy exchange of letters with Wolfgang Pauli. On Pauli’s death in 1958, his widow, Franca, deliberately destroyed all the letters von Franz had sent to her husband, and which he had kept locked inside his writing desk. However, the letters from Pauli to von Franz were all saved and were later made available to researchers and published.

Synchronicity has been is among the most developed ideas by Jung’s followers, notably by Michel Cazenave, James Hillman, Roderick Main, Carl Alfred Meier and by the British developmental clinician, George Bright. It has been explored also in a range of spiritual currents who have sought in it a scientific rigour.

Although Synchronicity as conceived by Jung within the bounds of the science available in his day, has been categorised as pseudoscience, recent developments in complex adaptive systems argue for a revision of such a view. Critics cite that Jung’s experiments that sought to provide statistical proof for this theory did not yield satisfactory result. His experiment was also faulted for not using a true random sampling method as well as for the use of dubious statistics and astrological material.

Post-Jungian Approaches

Andrew Samuels (1985) has distinguished three distinct traditions or approaches of “post-Jungian” psychology – classical, developmental and archetypal. Today there are more developments.

Classical

The classical approach tries to remain faithful to Jung’s proposed model, his teachings and the substance of his 20 volume Collected Works, together with recently published works, such as the Liber Novus, and the Black Books. Prominent advocates of this approach, according to Samuels (1985), include Emma Jung, Jung’s wife, an analyst in her own right, Marie-Louise von Franz, Joseph L. Henderson, Aniela Jaffé, Erich Neumann, Gerhard Adler and Jolande Jacobi. Jung credited Neumann, author of “Origins of Conscious” and “Origins of the Child”, as his principal student to advance his (Jung’s) theory into a mythology-based approach. He is associated with developing the symbolism and archetypal significance of several myths: the Child, Creation, the Hero, the Great Mother and Transcendence.

Archetypal

One archetypal approach, sometimes called “the imaginal school” by James Hillman, was written about by him in the late 1960s and early 1970s. Its adherents, according to Samuels (1985), include Gerhard Adler, Irene Claremont de Castillejo, Adolf Guggenbühl-Craig, Murray Stein, Rafael López-Pedraza and Wolfgang Giegerich. Thomas Moore also was influenced by some of Hillman’s work. Developed independently, other psychoanalysts have created strong approaches to archetypal psychology. Mythopoeticists and psychoanalysts such as Clarissa Pinkola Estés who believes that ethnic and aboriginal people are the originators of archetypal psychology and have long carried the maps for the journey of the soul in their songs, tales, dream-telling, art and rituals; Marion Woodman who proposes a feminist viewpoint regarding archetypal psychology. Some of the mythopoetic/archetypal psychology creators either imagine the Self not to be the main archetype of the collective unconscious as Jung thought, but rather assign each archetype equal value.[citation needed] Others, who are modern progenitors of archetypal psychology (such as Estés), think of the Self as the thing that contains and yet is suffused by all other archetypes, each giving life to the other.

Robert L. Moore has explored the archetypal level of the human psyche in a series of five books co-authored with Douglas Gillette, which have played an important role in the men’s movement in the United States. Moore studies computerese so he uses a computer’s hard wiring (its fixed physical components) as a metaphor for the archetypal level of the human psyche. Personal experiences influence the access to the archetypal level of the human psyche, but personalized ego consciousness can be likened to computer software.

Developmental

A major expansion of Jungian theory is credited to Michael Fordham and his wife, Frieda Fordham. It can be considered a bridge between traditional Jungian analysis and Melanie Klein’s object relations theory. Judith Hubback and William Goodheart MD are also included in this group. Andrew Samuels (1985) considers J.W.T. Redfearn, Richard Carvalho and himself as representatives of the developmental approach. Samuels notes how this approach differs from the classical by giving less emphasis to the Self and more emphasis to the development of personality; he also notes how, in terms of practice in therapy, it gives more attention to transference and counter-transference than either the classical or the archetypal approaches.

Sandplay Therapy

Sandplay is a non-directive, creative form of therapy using the imagination, originally used with children and adolescents, later also with adults. Jung had stressed the importance of finding the image behind the emotion. The use of sand in a suitable tray with figurines and other small toys, farm animals, trees, fences and cars enables a narrative to develop through a series of scenarios. This is said to express an ongoing dialogue between the conscious and the unconscious aspects of the psyche, which in turn activates a healing process whereby the patient and therapist can together view the evolving sense of self.

Jungian Sandplay started as a therapeutic method in the 1950s. Although its origin has been credited to a Swiss Jungian analyst, Dora Kalff it was in fact, her mentor and trainer, Dr. Margaret Lowenfeld, a British paediatrician, who had developed the Lowenfeld World Technique inspired by the writer H.G. Wells in her work with children, using a sand tray and figurines in the 1930s. Jung had witnessed a demonstration of the technique while on a visit to the UK in 1937. Kalff saw in it potential as a further application of analytical psychology. Encouraged by Jung, Kalff developed the new application over a number of years and called it Sandplay. From 1962 she began to train Jungian Analysts in the method including in the United States, Europe and Japan. Both Kalff and Jung believed an image can offer greater therapeutic engagement and insight than words alone. Through the sensory experience of working with sand and objects, and their symbolic resonance new areas of awareness can be brought into consciousness, as in dreams, which through their frames and storyline can bring material into consciousness as part of an integrating and healing process. The historian of psychology, Sonu Shamdasani has commented:

Historical reflection suggests the spirit of Jung’s practice of the image, his engagement with his own figures, is indeed more alive in Sandplay than in other Jungian conclaves.

One of Dora Kalff’s trainees was the American concert pianist, Joel Ryce-Menuhin, whose music career was ended by illness and who retrained as a Jungian analyst and exponent of sandplay.

Process-Oriented Psychology

Process-oriented psychology (also called Process work) is associated with the Zurich-trained Jungian analyst Arnold Mindell. Process work developed in the late 1970s and early 1980s and was originally identified as a “daughter of Jungian psychology”. Process work stresses awareness of the “unconscious” as an ongoing flow of experience. This approach expands Jung’s work beyond verbal individual therapy to include body experience, altered and comatose states as well as multicultural group work.

The Analytic Attitude

Formally Jungian analysis differs little from psychoanalysis. However, variants of each school have developed overlaps and specific divergences through the century, or more, of their existence. They share a “frame” consisting of regular spatio-temporal meetings, one or more times a week, focusing on patient material, using dialogue which may consist of elaboration, amplification and abreaction and which may last on average three years (sometimes more briefly or far longer). The spatial arrangement between analyst and analysand may differ: seated face to face or the patient may use the couch with the analyst seated behind.

In some approaches alternative elements of expression can take place, such as active imagination, sandplay, drawing or painting, even music. The session may at times become semi-directed (in contrast to psychoanalytic treatment which is essentially a non-directive encounter). The patient is at the heart of the therapy, as Marie Louise von Franz has it in her work, “Psychotherapy: the practitioner’s experience”, where she recounts Jung’s thinking on that point. The transference is sought out (contrary to psychoanalytic treatment which distinguishes positive and negative transferences) and, the interpretation of dreams is one of the central pillars of Jungian psychotherapy. In all other respects, the rules correspond to those of classical psychoanalysis: the analyst examines free associations and tries to be objective and ethical, meaning respectful of the patient’s pace and rhythm of unfolding progress. In fact, the task of Jungian analysis is not merely to explore the patient’s past, but to connect conscious awareness with the unconscious such that a better adaptation to their emotional and social life may ensue.

Neurosis is not a symptom of the re-emergence of a repressed past, but is regarded as the functional, sometimes somatic, incapacity to face certain aspects of lived reality. In Jungian analysis the unconscious is the motivator whose task it is to bring into awareness the patient’s shadow, in alliance with the analyst, the more so since unconscious processes enacted in the transference provoke a dependent relationship by the analysand on the analyst, leading to a falling away of the usual defences and references. This requires that the analyst guarantee the safety of the transference. The responsibilities and accountability of individual analysts and their membership organisations, matters of clinical confidentiality and codes of ethics and professional relations with the public sphere are explored in a volume edited by Solomon and Twyman, with contributions from Jungian analysts and psychoanalysts. Solomon has characterised the nature of the patient – analyst relationship as one where the analytic attitude is an ethical attitude since:

The ethical attitude presupposes special responsibilities that we choose to adopt in relation to another. Thus, a parallel situation pertains between caregiver and child and between analyst and patient: they are not equal partners, but nevertheless are in a situation of mutuality, shared subjectivity, and reciprocal influence.

Jungian Social, Literary and Art Criticism

Analytical psychology has inspired a number of contemporary academic researchers to revisit some of Jung’s own preoccupations with the role of women in society, with philosophy and with literary and art criticism. Leading figures to explore these fields include the British-American, Susan Rowland, who produced the first feminist revision of Jung and the fundamental contributions made to his work by the creative women who surrounded him. She has continued to mine his work by evaluating his influence on modern literary criticism and as a writer. Leslie Gardner has devoted a series of volumes to analytical psychology in 21st century life, one of which concentrates on the “Feminine Self”. Paul Bishop, a British German scholar, has placed analytical psychology in the context of precursors such as, Goethe, Schiller and Nietzsche.

The Franco-Swiss art historian and analytical psychologist, Christian Gaillard, has examined Jung’s place as an artist and art critic in his series of Fay lectures at the Texas A&M University. These scholars draw from Jung’s works that apply analytical psychology to literature such as the lecture “On the Relation of Analytical Psychology to Poetry”. In this presentation, which was delivered in 1922, Jung stated that the psychologist cannot replace the art critic. He rejected the Freudian art criticism for reducing complex works of art to Oedipal fantasies of their creators, stressing the danger of simplifying literature to causes found outside of the actual work.

Criticism

Since its inception, analytical psychology has been the object of criticism, emanating from the psychoanalytic sphere. Freud himself characterised Jung as a “mystic and a snob”. In his introduction to the 2011 edition of Jung’s “Lectures on the Theory of Psychoanalysis”, given in New York in 1912, Sonu Shamdasani contends that Freud orchestrated a round of critical reviews of Jung’s writings from Karl Abraham, Jung’s former colleague at the Burghölzli hospital, and from the early Welsh Freudian, Ernest Jones. Such criticisms multiplied during the 20th century, focusing primarily on the “mysticism” in Jung’s writings. Other psychoanalysts, including Jungian analysts, objected to the cult of personality around the Swiss psychiatrist. It reached a crescendo with Jung’s perceived collusion with Nazism in the build up and during World War II and is still a recurrent theme. Thomas Kirsch writes: “Successive generations of Jungian analysts and analysands have wrestled with the question of Jung’s complex relations to Germany.” Other considered evaluations come from Andrew Samuels and from Robert Withers.

The French philosopher, Yvon Brès, considers that the concept of the collective unconscious, “shows also how easily one can slip from the psychological unconscious into perspectives from a universe of thought, quite alien from traditional philosophy and science, where this idea arose.” (“Le concept jungien d’inconscient collectif “témoigne également de la facilité avec laquelle on peut glisser du concept d’inconscient psychologique vers des perspectives relevant d’un univers de pensée étranger à la tradition philosophique et scientifique dans laquelle ce concept est né'”).

In his Le Livre Rouge de la psychanalyse (“Red Book of psychoanalysis”), the French psychoanalyst, Alain Amselek, criticises Jung’s tendency to be fascinated by the image and to reduce the human to an archetype. He contends that Jung dwells in a world of ideas and abstractions, in a world of books and old secrets lost in ancient books of spells (fr: grimoires). While claiming to be an empiricist, Amselek finds Jung to be an idealist, a pure thinker who has unquestionably demonstrated his intellectual talent for speculation and the invention of ideas. While he considers his epistemology to be in advance of that of Freud, Jung remains stuck in his intellectualism and in his narrow provincial outlook.[clarification needed] In fact, his hypotheses are determined by the concept of his postulated pre-existing world and he has constantly sought to find confirmations of it in the old traditions of Western Medieval Europe.

More problematic has been, at times, the ad hominem criticism of academics outside the field of analytical psychology. One, a Catholic historian of psychiatry, Richard Noll, wrote three volumes but was able to publish only the first two in 1994 and 1997. Nolls argued that analytical psychology is based on a neo-pagan Hellenistic cult. These attacks on Jung and his work prompted the French psychoanalyst, Élisabeth Roudinesco, to state in a review: “Even if Noll’s theses are based on a solid familiarity with the Jungian corpus […], they deserve to be re-examined, such is the detestation of the author for the object of his study that it diminishes the credibility of the arguments.” (“Même si les thèses de Noll sont étayées par une solide connaissance du corpus jungien […], elles méritent être réexaminées, tant la détestation de l’auteur vis-à-vis de son objet d’étude diminue la crédibilité de l’argumentation.”). Another, a French ethnographer and anthropologist, Jean-Loïc Le Quellec, criticised Jung over his alleged misuse of the term archetype and his “suspect motives” in dealings with some of his colleagues.

On This Day … 11 June

People (Births)

  • 1914 – Jan Hendrik van den Berg, Dutch psychiatrist and academic (d. 2012).

People (Deaths)

  • 1934 – Lev Vygotsky, Belarusian-Russian psychologist and theorist (b. 1896).

Jan Hendrik van den Berg

Jan Hendrik van den Berg (11 June 1914 to 22 September 2012) was a Dutch psychiatrist notable for his work in phenomenological psychotherapy (cf. phenomenology) and metabletics, or “psychology of historical change.” He is the author of numerous articles and books, including A different existence and The changing nature of man.

Between 1933 and 1936, he earned diplomas in primary school and high school education, the latter with a focus on mathematics. He also published papers on entomology. He then entered medical school at Utrecht University specialising in psychiatry and neurology. He completed his doctoral dissertation in 1946. One year later, after studying in both France and Switzerland, Dr. Van den Berg was appointed to Head of Department at the psychiatry clinic at Utrecht. At Utrecht, he lectured in psychopathology in the medical school and was also appointed to Professor of Pastoral Psychology in the theology department. In 1954, Dr. van den Berg took a position of Professor of Psychology at Leiden University. Since 1967, he has been a visiting professor at many universities and conducted lecture tours internationally.

Having lived most of his later life in a monumental house at the market in the historical centre of Woudrichem, he died in nearby Gorinchem.

Lev Vygotsky

Lev Semyonovich Vygotsky (Russian: Лев Семёнович Выго́тский; Belarusian: Леў Сямёнавіч Выго́цкі; 17 November 1896 to 11 June 1934) was a Soviet psychologist, known for his work on psychological development in children. He published on a diverse range of subjects, and from multiple views as his perspective changed over the years. Among his students was Alexander Luria.

He is known for his concept of the zone of proximal development (ZPD): the distance between what a student (apprentice, new employee, etc.) can do on their own, and what they can accomplish with the support of someone more knowledgeable about the activity. Vygotsky saw the ZPD as a measure of skills that are in the process of maturing, as supplement to measures of development that only look at a learner’s independent ability.

Also influential are his works on the relationship between language and thought, the development of language, and a general theory of development through actions and relationships in a socio-cultural environment.

Vygotsky is the subject of great scholarly dispute. There is a group of scholars who see parts of Vygotsky’s current legacy as distortions and who are going back to Vygotsky’s manuscripts in an attempt to make Vygotsky’s legacy more true to his actual ideas.

What is Child and Adolescent Psychiatry?

Introduction

Child and adolescent psychiatry (or paediatric psychiatry) is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families.

It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the paediatric population.

Brief History

When psychiatrists and paediatricians first began to recognise and discuss childhood psychiatric disorders in the 19th century, they were largely influenced by literary works of the Victorian era. Authors like the Brontë sisters, George Eliot, and Charles Dickens, introduced new ways of thinking about the child mind and the potential influence early childhood experiences could have on child development and the subsequent adult mind. When the Journal of Psychological Medicine and Mental Pathology, the first psychiatric journal in English, was published in 1848, child psychiatry didn’t exist as its own field yet. However, some of the earliest works on the possibility of nervous disorders and “insanity” in children were published in the Journal and several medical writers directly referenced works such as Jane Eyre (1847), Wuthering Heights (1847), Dombey and Son (1848), and David Copperfield (1850), to illustrate this new conceptualisation of the child mind. Until that time, it was generally accepted that children were free from nervous disorders and the “passions” that affected the adult mind.

As early as 1899, the term “child psychiatry” (in French) was used as a subtitle in Manheimer’s monograph Les Troubles Mentaux de l’Enfance. However, the Swiss psychiatrist Moritz Tramer (1882-1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria. The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894-1981), an Austrian émigré and medical graduate of the University of Berlin, under the direction of Adolf Meyer at the Johns Hopkins Hospital in Baltimore. Kanner was the very first physician to be identified as a child psychiatrist in the US and his textbook, Child Psychiatry (1935), is credited with introducing both the specialty and the term to the anglophone academic community. In 1936, Kanner established the first formal elective course in child psychiatry at the Johns Hopkins Hospital. In 1944 he provided the first clinical description of early infantile autism, otherwise known as Kanner Syndrome.

Maria Montessori together with It:Giuseppe Ferruccio Montesano and Clodomiro Bonfigli, two distinguished child psychiatrists, created in 1901 in Italy the “Lega Nazionale per la Protezione del Fanciullo” (National League for the Protection of Children). She gradually developed her own pedagogic method, initially based on the “intuition that the question of the ‘mentally deficient’ was more pedagogic than medical”. In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world’s first child guidance clinic. Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent’s biological aspects of brain functioning and IQ, but also the delinquent’s social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.

From its establishment in February 1923, the Maudsley Hospital, a South London-based postgraduate teaching and research psychiatric hospital, contained a small children’s department. Similar overall early developments took place in many other countries during the late 1920s and 1930s. In the United States, child and adolescent psychiatry was established as a recognised medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.

The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children. But it was not until the 1960s that the first NIH grant to study paediatric psychopharmacology was awarded. It went to one of Kanner’s students, Leon Eisenberg, the second director of the division.

The discipline has relatively flourished since the 1980s, in large part, because of contributions made in the 1970s, even if the outcomes for patients have been disappointing at times. It was a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by, Eva Frommer, Douglas Haldane, Michael Rutter, Robin Skynner and Sula Wolff, among others. The first comprehensive population survey of 9- to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children’s adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time, and the influence of social and contextual factors in children’s mental health, in their subsequent re-evaluation of the original cohort of children. These studies described the prevalence of ADHD (relatively low as compared to the US), identified the onset and prevalence of depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievement.

It was paralleled similarly by work on the epidemiology of autism that was to enormously increase the number of children diagnosed with autism in future years. Although attention had been given in the 1960s and ’70s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability. Since then, the DSM-IV and DSM-IVR have altered some of the parsing of psychiatric disorders into “childhood” and “adult” disorders, on the basis that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV). The American Psychiatric Association’s DSM is now on its fifth edition (DSM-5).

People in the field are sometimes referred to as “neurodevelopmentalists”. As of 2005 there was debate in the field as to whether “neurodevelopmentalist” should be made a new speciality.

In terms of patient outcomes, there is evidence that, in the United Kingdom at least on the 70th anniversary of the NHS, mental health remains a medical “Cinderella” (low priority) and the more so Child and Adolescent Health services which have been through repeated reorganisations and underinvestment all of which leads to disruption and loss of adequate provision.

“Modern neuroscience, genetics, epigenetics, and public health research has presented the tantalizing possibility that it can now be said with relative certainty that much (certainly not all) is understood about why some children struggle and others soar. Although it is an oversimplification, it can now be suggested that it is possible to understand how environmental factors, both negative and positive, influence the genome or epigenome, which in turn influence the structure and function of the brain and thus human thoughts, actions, and behaviors.”

Classification of Disorders

Not an exhaustive list:

  • Developmental disorders:
    • Autism spectrum disorder.
    • Learning disorders.
  • Disorders of attention and behaviour:
    • Attention deficit hyperactivity disorder.
    • Oppositional defiant disorder.
    • Conduct disorder.
  • Psychotic disorders:
    • Childhood schizophrenia.
  • Mood disorders:
    • Major depressive disorder.
    • Bipolar disorder.
    • Persistent Depressive Disorder.
    • Disruptive Mood Dysregulation Disorder.
  • Anxiety disorders:
    • Panic disorder.
    • Phobias.
  • Eating disorders:
    • Anorexia nervosa.
    • Bulimia nervosa.
  • Gender identity disorder:
    • Gender identity disorder in children.

Disorders are often comorbid. For example, an adolescent can be diagnosed with both major depressive disorder and generalised anxiety disorder. The incidence of psychiatric comorbidities during adolescence may vary by race, ethnicity and socioeconomic status, among other variables.

Clinical Practice

Assessment

The psychiatric assessment of a child or adolescent starts with obtaining a psychiatric history by interviewing the young person and their parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child’s emotional or behavioural problems, the child’s physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child’s problems. Collateral information is usually obtained from the child’s school with regards to academic performance, peer relationships, and behaviour in the school environment.

Psychiatric assessment always includes a mental state examination of the child or adolescent which consists of a careful behavioural observation and a first-hand account of the young person’s subjective experiences. The assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.

The assessment may be supplemented by the use of behaviour or symptom rating scales such as the Achenbach Child Behaviour Checklist or CBCL, the Behavioural Assessment System for Children or BASC, Connors Rating Scales (used for diagnosis of ADHD), Millon Adolescent Clinical Inventory or MACI, and the Strengths and Difficulties Questionnaire or SDQ. These instruments bring a degree of objectivity and consistency to the clinical assessment. More specialised psychometric testing may be carried out by a psychologist, for example using the Wechsler Intelligence Scale for Children, to detect intellectual impairment or other cognitive problems which may be contributing to the child’s difficulties.

Diagnosis and Formulation

The child and adolescent psychiatrist makes a diagnosis based on the pattern of behaviour and emotional symptoms, using a standardized set of diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV-TR) or the International Classification of Diseases (ICD-10). While the DSM system is widely used, it may not adequately take into account social, cultural and contextual factors and it has been suggested that an individualized clinical formulation may be more useful. A case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarising all the relevant factors implicated in the development of the patient’s problem, including biological, psychological, social and cultural perspectives (the “biopsychosocial model”). The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.

The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.

Treatment

Treatment will usually involve one or more of the following elements: behaviour therapy, cognitive behaviour therapy (CBT), problem-solving therapies, psychodynamic therapy, parent training programmes, family therapy, and/or the use of medication. The intervention can also include consultation with paediatricians, primary care physicians or professionals from schools, juvenile courts, social agencies or other community organisations.

In a review of existing meta-analyses and disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder), only for ADHD was the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders.

Training

In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 4 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialised training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry. Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.

Certification and Continuing Education

In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP). Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.

Shortage of Child and Adolescent Psychiatrists in the United States

The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. As of 2016, there are 7991 child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Centre for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. In 1999, however, the Surgeon General reported that “there is a dearth of child psychiatrists.” Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.

Cross-Cultural Considerations

Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.

Criticisms

Subjective Diagnoses

One criticism against psychiatry is that psychiatric diagnoses lack complete “objectivity,” particularly when compared with diagnoses in other medical specialties. However, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties. In 2013, Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgements rather than objective biological tests.”

Traditional deficit and disease models of child psychiatry have been criticised as rooted in the medical model which conceptualises adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterise problematic behaviour as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behaviour has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession: it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behaviour and symptoms, to promote a view of the “patient” as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behaviour, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability.

Prescription of Psychotropic Medications

Since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. In 2004 the US Food and Drug Administration (FDA) issued the Black Box Warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in paediatric patients. The most common diagnoses for which children receive psychiatric medication are ADHD, ODD, and conduct disorder.

Some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioural issues other than a psychotic disorder. In the United States, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families. More research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in paediatric populations. Because of the risk of metabolic syndrome and cardiovascular events with long-term antipsychotic use, use in paediatric populations is highly scrutinized and recommended in combination with psychotherapy and effective parent-training interventions.

Electroconvulsive Therapy

In 1947, child neuropsychiatrist Lauretta Bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ECT). These children received ECT daily for a typical course of approximately twenty treatments. This formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ECT, which is also known as either regressive ECT or annihilation therapy. In the 1950s Bender abandoned ECT as a therapeutic practice for the treatment of children. In the same decade the results of her published work on the use of ECT in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated. Commenting on his experience as part of Bender’s therapeutic program, Ted Chabasinski said that, “It really made a mess of me … I went from being a shy kid who read a lot to a terrified kid who cried all the time.” Following his treatment, he spent ten years as an inmate of Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Centre.

On This Day … 08 June

People (Births)

  • 1929 – Nada Inada, Japanese psychiatrist and author (d. 2013).
  • 1956 – Jonathan Potter, English psychologist, sociolinguist, and academic.

People (Deaths)

  • 1970 – Abraham Maslow, American psychologist and academic (b. 1908).

Nada Inada

Nada Inada (なだ いなだ, 08 June 1929 to 06 June 2013) was the pen-name of a Japanese psychiatrist, writer and literary critic active in late Shōwa period and early Heisei period Japan. His pen name is from the Spanish language phrase “nada y nada”.

Biography

Nada was born in the Magome district of Tokyo, but was raised for part of his youth in Sendai. He graduated from the Medical School of Keio University. One of his fellow students was Kita Morio, who encouraged his interest in literature and in the French language. He later travelled to France on a government scholarship. His wife was French.

Nada’s medical specialty was psychiatry, particularly in the treatment of alcoholism, and he was head of the Substance Abuse Department of National Hospital located in Yokosuka, Kanagawa.

One of his early novels, Retort, was nominated for the prestigious Akutagawa Prize.

Jonathan Potter

Jonathan Potter (born 08 June 1956) is Dean of the School of Communication and Information at Rutgers University and one of the originators of discursive psychology.

Jonathan Potter was born in Ashford, Kent, and spent most of his childhood in the village of Laughton, East Sussex; his father was a school teacher and his mother was a batik artist. He went to School in Lewes and then on to a degree in Psychology at the University of Liverpool in 1974 where he was exposed to the radical politics of the city, became (briefly) interested in alternative therapies, and responded to the traditional British empirical psychology that was the mainstay of the Liverpool psychology degree programme at the time. He read the work of John Shotter, Kenneth Gergen and Rom Harré and became excited by the so-called crisis in social psychology. This critical work led him to a master’s degree in philosophy of science at the University of Surrey where he worked on speech act theory and had a first exposure to post structuralism and in particular the work of Roland Barthes. He read and wrote about Thomas Kuhn, Paul Feyerabend and Imre Lakatos. At the same time, philosophy of science provided a pathway to the new sociology of scientific knowledge and in particular to the work of Harry Collins, Michael Mulkay and Steve Woolgar.

In 1979 he applied for a PhD funding at the University of Bath to work with Harry Collins. He was offered a place but in the summer of 1979 the offer was withdrawn after the incoming Thatcher government cut the budget for social science. He started a part-time PhD with Peter Stringer in Psychology at the University of Surrey, while also working on a project on overseas tourists’ experiences of Bath’s bed and breakfast hotels. In this period he met and started to live with Margaret Wetherell, who was doing a PhD with John Turner and was, with Howard Giles and Henri Tajfel, one of the key figures in British social psychology. He took part in the vibrant intellectual culture of social psychology in Bristol at the time although he was a lone voice against the broadly experimental focus of Bristol tradition of so-called European Social Psychology.

When Peter Stringer left Surrey to move to a Chair in the Netherlands Potter applied for DPhil funding again and started to work with Michael Mulkay at the University of York. He worked within the sociology of scientific knowledge tradition, focusing on recordings of psychologists debating with one another at conferences. Increasingly that work evolved into an analysis of scientific discourse.

When Margaret Wetherell was appointed to a post in St Andrews University in 1980 he moved to Scotland, doing his PhD long distance. In 1983 he gained his DPhil and started a temporary job whose primary duty was to teach statistics in the Psychological Laboratory (as the department was called at the time). Covering the statistics allowed him a lot of flexibility in other teaching and he developed a course simply called Discourse which covered speech act theory, implicature, semiotics, post-structuralism, critical linguistics and conversation analysis. The intensive engagement with this range of thinking influenced much of his later work.

After 4 years of temporary contracts at St Andrews he was offered a post at Loughborough University where he taught until July 2015, first as lecturer, then Reader in Discourse Analysis from 1992, then Professor of Discourse Analysis from 1996, and Head of Department from February 2010. At Loughborough he worked with and was influenced by Derek Edwards, Michael Billig, Charles Antaki and, more recently, Elizabeth Stokoe. Since 1996 he has lived with, and collaborated with, Alexa Hepburn. In the last decade he has taught workshops and short courses in Norway, Finland, Sweden, Denmark, Spain, Venezuela, New Zealand, Australia, US and the UK.

In 2005 his book Cognition and Conversation (jointly edited with Hedwig te Molder) received the inaugural prize of the American Sociological Association Ethnomethodology and Conversation Analysis section in 2007. In 2008 he was elected to UK Academy of Social Sciences.

Abraham Maslow

Abraham Harold Maslow (01 April 1908 to 08 June 1970) was an American psychologist who was best known for creating Maslow’s hierarchy of needs, a theory of psychological health predicated on fulfilling innate human needs in priority, culminating in self-actualisation.

Maslow was a psychology professor at Brandeis University, Brooklyn College, New School for Social Research, and Columbia University. He stressed the importance of focusing on the positive qualities in people, as opposed to treating them as a “bag of symptoms”.

A Review of General Psychology survey, published in 2002, ranked Maslow as the tenth most cited psychologist of the 20th century.

On This Day … 06 June

People (Births)

  • 1900 – Manfred Sakel, Ukrainian-American psychiatrist and physician (d. 1957).

People (Deaths)

  • 1961 – Carl Gustav Jung, Swiss psychiatrist and psychotherapist (b. 1875).

Manfred Sakel

Manfred Joshua Sakel (06 June 1900 to 02 December 1957) was an Austrian-Jewish (later Austrian-American) neurophysiologist and psychiatrist, credited with developing insulin shock therapy in 1927.

Sakel was born in Nadvirna (Nadwórna), in the former Austria-Hungary Empire (now Ukraine), which was part of Poland between the world wars. Sakel studied Medicine at the University of Vienna from 1919 to 1925, specializing in neurology and neuropsychiatry. From 1927 until 1933 Sakel worked in hospitals in Berlin. In 1933 he became a researcher at the University of Vienna’s Neuropsychiatric Clinic. In 1936, after receiving an invitation from Frederick Parsons, the state commissioner of mental hygiene, he chose to emigrate from Austria to the United States of America. In the US, he became an attending physician and researcher at the Harlem Valley State Hospital.

Dr. Sakel was the developer of insulin shock therapy from 1927 while a young doctor in Vienna, starting to practice it in 1933. It would become widely used on individuals with schizophrenia and other mental patients. He noted that insulin-induced coma and convulsions, due to the low level of glucose attained in the blood (hypoglycaemic crisis), had a short-term appearance of changing the mental state of drug addicts and psychotics, sometimes dramatically so. He reported that up to 88% of his patients improved with insulin shock therapy, but most other people reported more mixed results and it was eventually shown that patient selection had been biased and that it didn’t really have any specific benefits and had many risks, adverse effects and fatalities. However, his method became widely applied for many years in mental institutions worldwide. In the USA and other countries it was gradually dropped after the introduction of the electroconvulsive therapy in the 1940s and the first neuroleptics in the 1950s.

Dr. Sakel died from a heart attack on 02 December 1957, in New York City, NY, USA.

Carl Jung

Carl Gustav Jung (born Karl Gustav Jung, 26 July 1875 to 06 June 1961), was a Swiss psychiatrist and psychoanalyst who founded analytical psychology. Jung’s work has been influential in the fields of psychiatry, anthropology, archaeology, literature, philosophy, psychology and religious studies. Jung worked as a research scientist at the famous Burghölzli hospital, under Eugen Bleuler. During this time, he came to the attention of Sigmund Freud, the founder of psychoanalysis. The two men conducted a lengthy correspondence and collaborated, for a while, on a joint vision of human psychology.

Freud saw the younger Jung as the heir he had been seeking to take forward his “new science” of psychoanalysis and to this end secured his appointment as President of his newly founded International Psychoanalytical Association. Jung’s research and personal vision, however, made it impossible for him to follow his older colleague’s doctrine and a schism became inevitable. This division was personally painful for Jung and resulted in the establishment of Jung’s analytical psychology as a comprehensive system separate from psychoanalysis.

Among the central concepts of analytical psychology is individuation – the lifelong psychological process of differentiation of the self out of each individual’s conscious and unconscious elements. Jung considered it to be the main task of human development. He created some of the best known psychological concepts, including synchronicity, archetypal phenomena, the collective unconscious, the psychological complex and extraversion and introversion.

Jung was also an artist, craftsman, builder and a prolific writer. Many of his works were not published until after his death and some are still awaiting publication.

On This Day … 04 June

People (Deaths)

  • 1922 – W.H.R. Rivers, English anthropologist, neurologist, ethnologist, and psychiatrist (b. 1864).

W.H.R. Rivers

William Halse Rivers Rivers (12 March 1864 to 4 June 1922) was an English anthropologist, neurologist, ethnologist and psychiatrist, best known for his work treating First World War officers who were suffering from shell shock in order to return them to combat. Rivers’ most famous patient was the poet Siegfried Sassoon, with whom he remained close friends until his own sudden death.

During the early years of the 20th century, Rivers developed many new lines of psychological research. In addition, he was the first to use a type of double-blind procedure in investigating physical and psychological effects of consumption of tea, coffee, alcohol, and drugs. For a time he directed centres for psychological studies at two colleges, and he was made a Fellow of St John’s College, Cambridge. He is also notable for having participated in the Torres Strait Islands expedition of 1898 and his consequent seminal work on the subject of kinship.

What was the Kirkbride Plan?

Introduction

The Kirkbride Plan was a system of mental asylum design advocated by Philadelphia psychiatrist Thomas Story Kirkbride (1809-1883) in the mid-19th century.

The asylums built in the Kirkbride design, often referred to as Kirkbride Buildings (or simply Kirkbrides), were constructed during the mid-to-late-19th century in the United States. The structural features of the hospitals as designated by Dr. Kirkbride were contingent on his theories regarding the healing of the mentally ill, in which environment and exposure to natural light and air circulation were crucial. The hospitals built according to the Kirkbride Plan would adopt various architectural styles, but had in common the “bat wing” style floor plan, housing numerous wings that sprawl outward from the centre.

1848 lithograph of the Kirkbride design of the Trenton State Hospital.

The first hospital designed under the Kirkbride Plan was the Trenton State Hospital in Trenton, New Jersey, constructed in 1848. Throughout the remainder of the nineteenth century, numerous psychiatric hospitals were designed under the Kirkbride Plan across the United States. By the twentieth century, popularity of the design had waned, largely due to the economic pressures of maintaining the immense facilities, as well as contestation of Dr. Kirkbride’s theories amongst the medical community.

Numerous Kirkbride structures still exist today, though many have been demolished or partially-demolished and repurposed. At least 30 of the original Kirkbride buildings have been registered with the National Register of Historic Places in the United States, either directly or through their location on hospital campuses or in historic districts.

Background

Basis and Philosophy

The establishment of state mental hospitals in the US is partly due to reformer Dorothea Dix, who testified to the New Jersey legislature in 1844, vividly describing the state’s treatment of lunatics; they were being housed in county jails, private homes, and the basements of public buildings. Dix’s effort led to the construction of the New Jersey State Lunatic Asylum, the first complete asylum built on the Kirkbride Plan.

Thomas Story Kirkbride (1809-1883), a psychiatrist from Philadelphia, Pennsylvania, developed his requirements of asylum design based on a philosophy of Moral Treatment and environmental determinism. The typical floor plan, with long rambling wings arranged en echelon (staggered, so each connected wing received sunlight and fresh air), was meant to promote privacy and comfort for patients. The building form itself was meant to have a curative effect, “a special apparatus for the care of lunacy, [whose grounds should be] highly improved and tastefully ornamented.” The idea of institutionalisation was thus central to Kirkbride’s plan for effectively treating the insane.

Design and Architectural Features

The Kirkbride Plan asylums tended to be large, imposing institutional buildings, with the defining feature being their “narrow, stepped, linear building footprint” featuring staggered wings extending outward from the centre, resembling the wingspan of a bat. The standard number of wings for a Kirkbride Plan hospital was eight, with an accommodation of 250 patients. Kirkbride’s philosophy behind the staggered wings was to allow individual corridors open to sunlight and air ventilation through both ends, which he believed aided in healing the mentally ill. Each wing, according to Kirkbride’s original guidelines, would house a separate ward, which would contain its own “comfortably furnished” parlour, bathroom, clothes room, and infirmary, as well as a speaking tube and dumbwaiter to allow open communication and movement of materials between floors. The furthest wings from the centre complex of the building were reserved for the “most excitable,” or most physically dangerous and volatile patients. Patient rooms were suggested to be spacious, with ceilings “at least 12 feet (3.7 m) high,” but only large enough to room a single person. The centre complexes of the Kirkbride Plan buildings were designed to house administration, kitchens, public and reception areas, and apartments for the superintendent’s family. Architectural styles of Kirkbride Plan buildings varied depending on the appointed architect, and ranged from Richardsonian Romanesque to Neo-Gothic.

In addition to the intricate building design, Dr. Kirkbride also advocated the importance of “fertile” and spacious landscapes on which the hospitals would be built, with views that “if possible, should exhibit life in its active forms.” Kirkbride also suggested the hospital grounds be a minimum of 100 acres (40 ha) in size. The foliage and farmlands on the hospital grounds were sometimes maintained by patients as part of physical exercise and/or therapy. Over the course of the nineteenth and twentieth centuries, the campuses of these hospitals often evolved into sprawling, expansive grounds with numerous buildings.

Operations and Staffing

In his proposal, Dr. Kirkbride outlined specific guidelines as to how a Kirkbride Plan hospital should be staffed and operate on a daily basis. Dr. Kirkbride suggested a total of 71, all of whom were required to live within, or in the immediate vicinity of, the hospital. The superintending physician, or physician-in-chief, was required to live in the main hospital or in a building contiguous to it, while his family had the option of residing at the hospital or seeking private lodging. The staff was also to have a balanced gender distribution, with approximately 36 female and 35 male staff members.

Among the staff of a Kirkbride Plan hospital were the superintending physician, an assisting physician and nurses, supervisors and teachers of each sex, a chaplain, matron, and a nightwatchman. Kirkbride urged that at least two attendants be working in each ward at any given time, and stressed the importance of the superintendent’s “proper selection” of attendants, given the extent of their management responsibilities: “The duties of attendants, when faithfully performed, are often harassing, and in many wards, among excited patients, are peculiarly so. On this account pains should always be taken to give them a reasonable amount of relaxation and their position should, in every respect, be made as comfortable as possible.” For general labour at the hospital, he suggested that the able-minded patients help maintain the hospital grounds and assist in duties in their respective wards.

Dr. Kirkbride’s estimation of the number of staff as well as their respective compensations was outlined in an 1854 publication on the Kirkbride Plan design. He proposed a living wage for all employees of the hospital, noting that “although in a few institutions a liberal compensation is given, in many, the salaries are quite too low, and entirely inadequate to be depended on, to secure and retain the best kind of talent for the different positions. The services required about the insane, when faithfully performed, are peculiarly trying to the mental and physical powers of any individual, and ought to be liberally paid for.” Salary for the superintending physician according to the 1854 guideline was to be USD$1,500 (equivalent to $43,206 in 2020) if the physician’s family resided at the hospital, and $2,500 (equivalent to $72,009 in 2020) if they found lodging at a private residence. In addition to the medical staff and attendants, the Kirkbride Plan hospitals also employed labourers of various trades, including resident engineers, carpenters, cooks and dairymaids, gardeners, seamstresses, ironworkers, clothing launderers, and a carriage driver.

Decline and Phasing Out

By the late-nineteenth century, the Kirkbride design had begun to wane in popularity, largely because the hospitals (which were state-funded), had received significant budget cuts that rendered them difficult to maintain. General psychiatric and medical opinion of Kirkbride’s theories regarding the “curability” of mental illness were also questioned by the medical community.

Future

Status

A total of 73 known Kirkbride Plan hospitals were constructed throughout the United States between 1845 and 1910. As of 2016, approximately 33 of these identified Kirkbride Plan hospital buildings still exist in their original form to some degree: 24 have been preserved indicating that the building is still standing and still in use, at least, in part. 11 of the 24 preserved properties received secondary condition codes of deteriorating, vacant, partial demolition or a combination, while the remaining nine have been adaptively reused. Of the 40 hospital buildings that no longer exist (either via demolition or destruction from natural occurrences, such as earthquakes), 26 were demolished to be replaced with new facilities.

The highest concentrations of Kirkbride Plan hospitals were in the Northeast and Midwestern states. Fewer Kirkbride Plan hospitals were constructed on the West Coast: In California, the Napa State Hospital was a notable Kirkbride Plan hospital, though the original structure was severely damaged during the 1906 San Francisco earthquake, and was ultimately demolished. The two surviving Kirkbride structures on the West Coast are both located in the state of Oregon, at the Oregon State Hospital, and the Eastern Oregon State Hospital, the latter of which now houses the Eastern Oregon Correctional Institution. While the vast majority of Kirkbride hospitals were located in the United States, similar facilities were built in Canada, and the Callan Park Hospital for the Insane in Sydney, Australia (constructed in 1885) was also influenced by Kirkbride’s design.

Preservation Efforts

Due to their intricate architectural features and historical significance, Kirkbride Plan hospitals have attracted conservation efforts from local and national groups, and (as of 2016) approximately 30 of the buildings have been registered with National Register of Historic Places. Local conservation groups and historical societies have made attempts to save numerous Kirkbrides from demolition: The Danvers State Hospital in Danvers, Massachusetts is one example, in which a local historical society filed a lawsuit in 2005 to stall demolition of the building. The majority of the Danvers State Hospital was demolished in 2007 in spite of the lawsuit, with only the centre portion of the building receiving restoration and conversion into apartments. The Northampton State Hospital in Northampton, Massachusetts, was demolished in 2006.

Many of the surviving Kirkbride Plan buildings in the United States have undergone at least partial demolition and have been repurposed, often with the centre portions of the buildings being most commonly preserved. The centre complexes of the Hudson River State Hospital in Poughkeepsie, New York, and the Oregon State Hospital in Salem, Oregon, for example, have been retained in spite of the majority of the outermost wings being demolished. One such Kirkbride Plan facility that has survived in its entirety is the Trans-Allegheny Lunatic Asylum, though does not contemporarily function as an active hospital. As of 2017, Trans-Allegheny Lunatic Asylum has not undergone demolition.

Several facilities originally established as Kirkbride Plan hospitals are still active in the 21st century, though not all have retained the original Kirkbride buildings on their campuses. The Oregon State Hospital, the longest continuously-operated psychiatric hospital on the West Coast, retained the majority of its original Kirkbride building during a 2008 demolition, seismically retrofitting and repurposing it as a mental health museum in 2013.

In Popular Culture

Numerous Kirkbride Plan hospitals and buildings have been featured in the arts: the Danvers State Hospital in Danvers, Massachusetts was both the setting and primary filming location for the 2001 psychological horror film Session 9. It has also been suggested by historians as an inspiration on H.P. Lovecraft, and in turn an inspiration for the fictional setting Arkham Asylum in the various Batman series. The Oregon State Hospital was also featured as the primary filming location for the film One Flew Over the Cuckoo’s Nest (1975), and was also the setting of “Ward 81,” a 1976 series of photographs by photographer Mary Ellen Mark.

The Trans-Allegheny Lunatic Asylum in West Virginia was featured on the Travel Channel reality series Ghost Adventures.