Essay // Psychoanalysis: History, Foundations, Legacy, Impact & Evolution

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History and Background

In contemporary psychology, the psychoanalytic movement’s place is both unique and paradoxical. Focussing on the study of the mind as a “software” running on the brain as the “hardware”, psychoanalysis remains the only discipline that truly focuses on the mechanism and processes behind our thoughts. Unlike empirical behavioural science and other “cogno-sciences” that can be fairly barbaric and obstinate in the forced application of the rigid mathematical and systematic procedures embedded in the classic scientific method when dealing with an entity as complex and organic as the human mind; psychoanalysis has remained focussed in understanding human psychology by capturing it in all its details, depths, dimensions and linguistic aspects.

The scientific method although a proven mathematical approach to inquiries in the hard sciences [e.g. biology, medecine, physics, chemistry, astrophysics, material science, astronomy, etc], shows its limitations when used as a tool for psychological inquiry in the measurement of variables that are incredibly hard to measure such as emotions, values, motives, desires, libidinous intensity or dreams. It is also fair noting that humans are different from simple organisms, molecules or robots, hence psychoanalysis remains the only discipline focused on the mind [the software] assuming that most human beings have a physiologically healthy brain [the hardware].

However, modern sciences have discovered how abnormalities in the brain’s physiology due to birth defects or injury may result in behavioural problems linked to a deficient mind due to the defective brain [hardware] at its disposal. Hence, nowadays most good intellectuals in the field of psychoanalysis would likely be a better psychologist with an in-depth knowledge of the physiology of the brain, i.e. the major areas affecting core functions such as speech [Wernicke and Broca’s], vision [the occipital lobe], and motor abilities [parietal lobe], etc.

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This is because some psychological problems may on rare occasion be caused by brain injuries or physiological abnormality due to virus, trauma, stroke or injury. In those cases where such a scenario materialises, the psychotherapist may refer the patient to a neurosurgeon who may be more appropriate to inspect the extent of the problems on the defective brain [hardware] which may lead to a clearer perspective of the limitations being imposed on the mind of the affected individual and how it impacts processes such as the conscious, the preconscious and the unconscious [based on Sigmund Freud’s 1st ground breaking theory of mental life, the Topographic Model, which was also adopted by Jacques Lacan who argued convincingly that post-Freudian psychoanalysts had swayed too far from the fundamental concepts and turned psychoanalysis into a confusing genre].

However, as we are in the developmental stages of conception of the organic theory, a theory that takes the focus on the individual organism’s creative ability to another level, we are going to remain focussed on the mind. The organic theory was inspired by the brain’s magnificent ability to learn any age, and thus give the individual human organism the ability and freedom to define, create, redefine, recreate and shape itself based on its inherited and acquired abilities, desires and personal constructionist developments throughout its life – yes, the individual does have choices and these impact the person’s internal working model of mental life and the person as a whole along with his or her environment.

While psychoanalysis remains one of the most widely known schools of psychology it is perhaps not universally understood. The founder of psychoanalysis, Sigmund Freud is perhaps one of the most famous psychologist of the last century even if his chosen discipline, psychoanalysis, has little in common with the other schools of thought and psychology.

Psychoanalysis views the mind as an active, dynamic and self-generating entity, and this is in the German tradition of mental life [it was also a founding assumption for Jean Piaget as he developed his Theory of Cognitive Development in Children].

Exploding Raphaelesque Head - Salvador Dali (1951) dpurb d'purb website

« Tête Raphaélesque Éclatée » par Salvador Dali (1951)

It is also important to note that Freud was trained in hard sciences, yet his system shows little appreciation for systematic and reductionist empiricism. As a physician, Freud used his observational skills to build his system within a medical framework, basing his theory on individual case studies. He did not depart from his understanding of 19th-century science in the effort to organise his observations, neither did he attempt to test his hypotheses rigorously through independent verification. As he testified, he was psychoanalysis and did not tolerate dissension from his orthodox views. Nevertheless, Freud had a tremendous impact on 20th century psychology, perhaps more importantly, the influence of psychoanalysis on Western thought, as reflected in literature, philosophy and art, significantly exceeds the impact any other system of psychology.

 

The Active Mind

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Photographie: Danny D’Purb © 2012

Going back to the philosophical foundations of modern psychology in Germany during the 17th, 18th and 19th centuries, we found that the tradition of Leibniz and Kant clearly emphasised mental activity. This is in contrast to British empiricism, which assumed the mind to be a passive entity [such as a sponge that simply soaks in what is thrown at it]. The German tradition held the most logical and creative assumption that the mind itself generates and structures human experience in characteristic ways [being « active »]. Whether through Leibniz’s monadology or Kant’s categories, the psychology of the individual could be understood only by examining the dynamic, inherent activity of the mind.

Throughout the years, as psychology evolved into an independent discipline in the latter part of the 19th century under Wundt’s tutelage, the British model of mental passivity served as a guiding philosophy. Clearly, Wundt’s empiricistic formulation was at odds with German philosophical precedents, recognised by both Stumpf and Brentano. Act psychology and the psychology of non-sensory consciousness represented by the Würzburg School were closer to the German philosophical assumptions of mental activity than to Wundt’s structural psychology. The Gestalt movement encompassed these alternatives to Wundt’s psychology in Germany. Eventually, as the rational outcome guided intellectuals, Wundt’s system was replaced by Gestalt psychology, turning into the dominant psychology in Germany prior to World War II – one based on a model of the mind that admitted inherent organisational activity.

The assumptions underlying mental activity in Gestalt psychology were highly qualified, where construct for mind involves the organisation of perception, based on the principle of isomorphism, which resulted in a predisposition toward patterns of personal-environmental interactions. The focus on organisation meant that the way of mental processes, not their content, was inherently structured. In other words, individuals were not born with specific ideas, energies, or other content in the mind; rather, the organisational structure was inherited to acquire mental contents in characteristic ways. Accordingly, the Gestalt movement, while rightly rejecting the rigidity of Wundt’s empiricistic assumptions and concepts, did not reject empiricism completely [as a technique to study some basic and easily defined variables (such as traits) and their relation(s) to others]. Instead, the Gestaltists advocated a compromise between the empiricist basis of British philosophy and the German model of activity. Consequently, this opened psychological investigation to the study of complex problem-solving and perceptual processes.

Consistent with the Gestalt foundations, psychoanalysis was firmly grounded in an active model of mental processes, however it shared little of the Gestalt commitment to empiricism. Freud’s views on personality were consistent not only with the activities of mental processing suggested by Leibniz and Kant, but also with the 19th century belief in conscious and unconscious levels of mental activity. In acknowledging the teachings of such philosophers as Von Hartman and Schopenhauer [Read the Essay on our Review of « Die Welt als Wille und Vorstellung »(The World as Will and Idea), Freud developed motivational principles that depended on energy forces beyond the level of self-awareness.

Schopenhauer

Arthur Schopenhauer (1788 – 1860)

Moreover, for Freud, the development of personality was determined by individual, unconscious adaptation to these forces. The details of personality development as formulated by Freud are outlined below; however, is also important to recognise the fundamental basis of Freud’s thinking. Psychoanalysis is based on the implication of mental activity further than any other system of psychology. As a major representative of a reliance on mental activity to account for personality, psychoanalysis is set apart from other movements in contemporary psychology. In addition, psychoanalysis unlike the other branches of psychology, did not emerge from reductionist empirical research that stubbornly tries to apply mechanical scientific methodology to measure complex non-physical abilities; rather it was the product of the applied consequences of clinical practice [i.e. it was a force that was born on the field to treat mental problems as they surfaced throughout human history].

 

The Treatment of Mental Illness

Besides being the founder of the psychoanalytic movement in modern psychology, Freud is also remembered for his efforts in pioneering the upgrade in the treatment of mental and behavioural abnormalities, and was instrumental in psychiatry’s recognition as a branch of medicine that specifically deals with psychopathology. Before Freud’s works in attempting to devise effective methods of treating the mentally ill, individuals who deviated from socially acceptable norms were usually treated as if they were criminals or demonically possessed. Although shocking controversies in the contemporary treatment of mental deviancy appear occasionally, not too long ago such abuses were often the rule rather than the exception.

The treatment of mental illnesses was never a pleasant chapter in Western civilisation and it has been pointed out many times that abnormal behaviour is often mixed up with criminal behaviour as with heresy and treason. Even during the period of enlightenment during the European Renaissance, the cruelties and tortures of the inquisition were readily adapted to treat what we nowadays qualify as mental illness. Witchcraft continued to offer a reasonable explanation to such eccentric behaviour until recent times. Prisons were established to house criminals, paupers, and the insane without any differentiation. Mental illness was viewed as governed by evil or obscure forces, and the mentally ill were looked upon as crazed by such weird influences such as moon rays. Lunatics or “moonstruck” persons, were appropriately kept in lunatic asylums. As recently as the latter part of the 19th century and the beginning of the 20th century, the institution of for the insane in Utica, New York, which was progressive by the standards of the time, was called the Utica Lunatic Asylum. The name reflected the prevailing attitude toward mental illness.

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« Dr. Philippe Pinel at the Salpêtrière », 1795 by Tony Robert-Fleury. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women

Reforms in the treatment of the institutionalised insane were slowly introduced during the 19th century. In 1794, Philippe Pinel (1745 – 1826) was appointed the chief of hospitals for the insane in Paris, and managed to improve both the attitude toward and the treatment of the institutionalised insane. In the United States, Dorothea Dix (1802 – 1887) accomplished the most noticeable reforms in the treatment of the mentally ill. Beginning in 1841, Dix led a campaign to improve the condition of indigent, mentally ill persons kept in jails and in poorhouses. However, these reforms succeeded in improving only the physical surroundings and maintenance conditions of the mentally ill; legitimate treatment was minimal. [Even today, in 2019, the US seems to have more people with eccentric behaviours and with questionable mental stability, for example, Donald Trump, who has been singled out as being mentally ill by more than one. See: (1) The Dangerous Case of Donald Trump, (2) Trump Is ‘Mentally Ill’ Says Former Vermont Governor and Doctor Howard Dean, (3) American psycho? Donald Trump’s mental health is still a question, (4) Psychiatrist: Trump Mental Health Urgently Deteriorating & (5) Stanford’s Zimbardo asks: Is President Trump mentally ill?

Confidence in US

Around the world, favorability of the U.S. and confidence in its president decline / Source: Pew Research Center

The US has more women in prison than China, India & Russia combined

According to the International Centre for Prison Studies, nearly a third of all female prisoners worldwide are incarcerated in the United States of America. There are 201,200 women in US prisons, representing 8.8 percent of the total American prison population. / Source: Forbes

Most people in prison

Highest to Lowest – Prison Population Total / Source: World Prison Brief

Efforts to develop comprehensive treatments were plagued by various quacks, such as the pseudoscience developed by Mesmer that dealt with the “animal spirit” underlying mental illnesses [although it may be true today if expressed as a metaphorical description to some of the behavioural manifestations of some mental disorders in some individuals].

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« White Dogs and Tootsie Pops » by Marie Hughes

Similarly, the phrenology of Gall and Spurzheim advocated a physical explanation based on skull contours and localisation of brain functions – which was of course also wrong.

Gradually however, attempts were made to develop legitimate and effective techniques to treat emotional and behavioural abnormalities. One of the more productive investigations involved hypnotism and was pioneered by a French physician, Jean Martin Charcot (1825 – 1893). Charcot gained widespread fame in Europe, and the young Freud amazed by his abilities, studied under him, as did many other talented physicians and physiologists. He treated hysterical patients with symptoms ranging from hyper-emotionality to physical conversions of underlying emotional problems that the patient could not confront when conscious.

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Une leçon clinique à la Salpêtrière (1887) » with Jean Martin Charcot in Front (A Clinical Lesson at the Salpêtrière) par André Brouillet à l’Université Paris Descartes

Another French physician in Nancy, namely Hippolyte Bernheim (1837 – 1919), developed a sophisticated analysis of hypnosis as a form of treatment, using underlying suggestibility to alter the intentions of the patient. Finally, Pierre Janet (1859 – 1947), a student of Charcot, used hypnotism to resolve the forces of emotional conflict, which he believed were basic to hysterical symptoms. However, it was Sigmund Freud who went beyond the techniques of hypnotism to develop a comprehensive theory of psychopathology from which systematic treatments evolved.

 

A Biography of Sigmund Freud

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Sigmund Freud (1856 – 1939) / Image: Freud Museum London

Since psychoanalysis as we know it today is hugely influenced by the foundations laid by Sigmund Freud, it is worthwhile to have an understanding about the major points in his life. Sigmund Freud (1856 – 1939) was born on the 6th of May 1856 in Freiberg, Moravia, at that time a norther province of the Austro-Hungarian Empire, today a part of the Czech Republic.

Freud was the eldest of 8 children, and his father was a relatively poor and not very successful wool merchant. When his business failed, Freud’s father moved with his wife and children [as many jews are accustomed to migrating to better places in the quest for a better life and income] first to Leipzig and then to Vienna when Freud was 4 years old. The young Freud remained in Vienna for most of the rest of his life, and his precocious genius was recognised by his family, and he was allowed many concessions and favours not permitted to his siblings. For example, young Freud was provided with better lighting to read in the evening, and when he was studying, noise in the house was kept to a minimum so he would not be disturbed.

Freud’s interest were varied and intense, and he showed an early inclination and aptitude for various intellectual pursuits. Unfortunately, Freud was a victim of the 19th century Jew-dislike which was obvious and severe in central and Eastern Europe after the numerous accounts of Jews being banished from places all over Europe due to their occult and violent religious practices on Christian infants [e.g. human sacrifices] along with their known habits in monopolising the majority of the press businesses to then distort news and heritage to their agendas and economic advantage.

However, although Freud was an atheist and more scientifically minded, his Jewish birth precluded certain career opportunities, most notably an academic career in university research. Indeed, medicine and law were the only professions open to Vienna Jews.

Freud’s early reading of Charles Darwin intrigued and impressed him to the point that a career in science was most appealing. The closest path that he could follow for training as a researcher was an education in medicine. Hence, Freud entered the university of Vienna in 1873 at the age of 17. However, because of his interests in a variety of fields and specific research projects, it took him 8 years to complete the medical coursework that normally required 6 years.

Eel

In 1881, he received his doctorate in medicine. While at university, Freud was part of an investigation of the precise structure of the testes of eels, which involved his dissecting over 400 eels. Later, he moved on to physiology and neuroanatomy and conducted experiments examining the spinal cord of fish. While at Vienna, Freud also took courses with Franz Brentano, which formed his only formal introduction to 19th century psychology.

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After waiting for Freud for about 4 years, his fiancée, Martha Bernays, a jewish girl from a business family and the grand-daughter of a famous Rabbi in Hamburg, married him. While she did not show great interest in Freud’s intellectual pursuits, her younger sister Minna became a very close intellectual partner of Freud. Carl Jung one of Freud’s intellectual ally who would become one of his firmest critic would even later say that he learned from Minna that Freud was in love with her and their relationship was very “intimate” – although we have no factual confirmation of such. She was so close to the young couple, that she moved in with them in the 1890s to set up was has been “jokingly” called a “ménage a trois”. As for Martha, she was also a charmer, intelligent, well-educated and fond of reading who as a married woman ran her household efficiently and was almost obsessive about punctuality and dirt. Firm but loving with her children, French analyst René Laforgue said that she spread an atmosphere of peaceful joie de vivre through the household. Shortly after Freud’s wedding, he recognised that a scientific career would not provide adequate income, since anti-Jewish sentiments were strong around Europe and this worked against Jewish advancement in academia even if Freud himself was not a practising Jew or had any religious sentiments. So Freud reluctantly decided to begin a private practice. Although the young couple were very poor in the early years of their marriage, Freud was able to support his wife and his growing family, which eventually included 6 children. The early years in private practice were very difficult, requiring long hours for a meagre financial reward that basically did not challenge him. Freud was also an atheist and did not want psychoanalysis to be seen as a purely Jewish endeavour, and his close network although were mainly Jewish later slowly grew to incorporate European intellectuals where some of the most significant would disagree with some of his assumptions and leave his circle after keeping only a few of his fundamental concepts about the theory of mental life.

During his hospital training, Freud had worked with patients with anatomical and organic problems of the nervous system. Shortly after starting private practice, he became friendly with Josef Breuer (1842 – 1925), a general practitioner who had acquired some local fame for his respiration studies. This friendship provided needed stimulation for Freud, and they began to collaborate on several patients with nervous disorders, most notably the famous case of Anna O., an intelligent young woman with severe, diffuse hysterical symptoms. In using hypnosis to treat Anna O., Breuer noticed that some specific experiences emerged under hypnosis that the patient could not recall while conscious. Her symptoms seemed to be relieved after talking about these experiences under hypnosis. Breuer treated Anna O. daily for over a year, and became convinced that the “talking cure”, or “catharsis”, involving discussion of unpleasant and repulsive memories revealed under hypnosis, was an effective method in alleviating her symptoms. Unfortunately, Breuer’s wife became jealous of the relationship; that would later be called “positive transference of emotional feelings to the therapist” [this would later be explained as patients falling in love with the new object at which they had redirected feelings and desires retained in childhood] at characteristic stages of therapy, this looked suspicious to her. As a result, Breuer terminated his treatment of Anna O. Freud was also very professional with his clients and never had any mistresses or took advantage of his female patients.

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Jean-Martin Charcot (1825 – 1893) / Charcot first began studying hysteria after creating a special ward for non-insane females with « hystero-epilepsy ». He discovered two distinct forms of hysteria among these women: minor hysteria and major hysteria. His interest in hysteria and hypnotism « developed at a time when the general public was fascinated in ‘animal magnetism’ and ‘mesmerization' », which was later revealed to be a method of inducing hypnosis.
Charcot argued vehemently against the widespread medical and popular prejudice that hysteria was rarely found in men, presenting several cases of traumatic male hysteria. He taught that due to this prejudice these « cases often went unrecognised, even by distinguished doctors » and could occur in such models of masculinity as railway engineers or soldiers. Charcot’s analysis, in particular his view of hysteria as an organic condition which could be caused by trauma, paved the way for understanding neurological symptoms arising from industrial-accident or war-related traumas.

In 1885, Freud received a modest grant that allowed him to go to Paris to study with Jean-Martin Charcot for 4 and half months. During that time he not only observed Charcot’s method of hypnosis [which he never managed to master as Charcot did] but also attended his lectures, learning about the master’s views on the importance of unresolved sexual problems in the underlying causality of hysteria. When Freud returned to Vienna, he gave a report of his work with Charcot to the medical society, but its cold reception left him with resentment that affected his future interactions with the entrenched medical establishment and its rigid and reductionist methods at understanding and solving the problems of the mind.

Freud continued his work with Breuer on hypnosis and catharsis, but gradually abandoned the former in favour of the latter, being not very gifted with hypnotic techniques, but also for 3 major reasons regarding its effectiveness as a treatment with general applicability. First, not everyone can be hypnotised; hence its usefulness is limited to a select group. Second, some patients refuse to believe what they revealed under hypnosis, prompting Freud to conclude that the patient must be aware during the step-by-step process of discovering memories hidden from their accessible consciousness. Third, when one set of symptoms were alleviated under hypnotic suggestibility, new symptoms often emerged. Freud and Breuer were moving in separate directions, and Freud’s increasing emphasis on the primacy of sexuality as the key to psychoneurosis contributed to their break. Nevertheless, in 1895 they published Studies on Hysteria, often cited as the first work of the psychoanalytic movement, although it sold only 626 copies during the following 13 years – perhaps due to the lack of sophistication and interest in the workings of the mind at that particular point in history, or the level of the academic discussions that may not have been adequate for the intellect of the average mind at the time.

Freud’s preferred method of treatment, catharsis, involves engaging with patients and encouraging them to speak of anything that comes [occupies] their mind, regardless of how discomforting or embarrassing it might be. This “free association” took place in a relaxed atmosphere, usually on the classic psychologist couch in a reclined position to promote comfort. The main reason behind the logic of catharsis and free association is that – like hypnosis – it would allow hidden thoughts and memories to manifest in consciousness. However, in contrast, to the method of hypnosis, the patient would be aware of these emerging recollections. Another ongoing process during free association is “transference”, which involves emotionally laden experiences that allow the patient to relieve earlier, repressed episodes. Since the psychoanalyst is often part of the transference process [as mentioned earlier where the repressed emotions are often redirected onto] and is often the object of emotions, Freud recognised transference as a powerful tool to assist the patient in resolving sources of anxiety.

In 1897, Freud began a self-analysis of his dreams, which evolved into another technique important to the psychoanalytic movement. In the analysis of dreams, Freud distinguish between the manifest content [the actual depiction of the dreams] and the latent content, which represented the symbolic world of the patient. In 1900, he published his major work, The Interpretation of Dreams. Although it sold only 600 copies in eight years, it later went through eight editions in his lifetime. In 1901, he published The Psychopathology of Everyday Life, the book in which his theory began to take shape. Freud argued that the psychology of all people, not only those with neurotic symptoms, could be understood in terms of the unconscious forces in need of resolution.

When his reputation as a pioneer in psychiatry started to grow due to his prolific writings, Freud attracted admiring followers, among them was the notable Carl Jung. In 1909, G. Stanley Hall, president of Clark University, invited him to the United States to give a lecture series as part of that institution’s 20th anniversary. The lectures were published in the American Journal of Psychology and later in book form, serving as an appropriate introduction to psychoanalytic thought for American audiences.

As psychoanalysis was perceived as radical by the medical establishment, early believers form their own associations and found the journals to disseminate their competing views. However, Freud’s demand for strict loyalty to his interpretation of psychoanalysis led to some discord within the movement [perhaps for the betterment of the field itself as many branches kept the fundamental concept of unconscious (Id), pre-conscious (SuperEgo), and conscious (Ego) but fused other theoretical and scientific perspectives to explain and treat a range of mental illnesses]. Carl Jung broke away in 1914, so that by the following year, three rival groups existed within the psychoanalysic movement. Nevertheless, Freud’s views continued to evolve. Impressed by the devastation and tragedy of World War I, Freud came to view aggression, along with sexuality, as a primal instinctual motivation. During the 1920s Freud expanded psychoanalysis from a method of treatment for mentally ill or emotionally disturbed persons to a systematic framework for all human motivation and personality.

In 1923, Freud developed cancer of the jaw and experienced almost constant pain for the remaining 16 years of his life. He underwent 33 operations and had to wear a prosthetic device. Throughout this ordeal however, he continued to write and see patients, although he shunned public appearances. With the rise of Hitler and the anti-Jewish sentiments that arose with his campaigns with the National Socialists, Freud’s works were unfortunately singled out as they were not seen as a scientific endeavour but rather as a Jewish science, and his books were burned throughout Germany. However, Freud resisted fleeing from Vienna. When Germany and Austria were politically united in 1938, the Gestapo began harassing Freud and his family. President Roosevelt indirectly relayed to the German government that Freud is an intellectual who must be protected. Nevertheless, in March 1938 some thugs invaded Freud’s home. Finally, through the efforts of friends, Freud was granted special permission, but only after promising to send for his unsold books in Swiss storage so that they could be destroyed. After he signed a statement saying that he had received good treatment from the police, the German government allowed him to leave for England, where he died shortly after, on September 23, 1939.

 

An overview of the Psychoanalytic System based on Freud’s Research

Before our in-depth examination of psychoanalytic theory, it is important to recognise that the theory has an unusually broad focus. Psychoanalysis contains a theory of personality, but it also offers theoretical tools for understanding culture, society, art and literature. It is also a clinical theory that aspires to explain the nature and origins of mental disorders, and that is associated with an approach to their treatment. To give some more sense to Freud’s breadth, consider that he wrote on topics as diverse as the meaning of dreams and jokes, the origins of religion, Shakespeare’s plays, the psychology of groups, homosexuality, the causes of phobias and obsessions, and much more besides. Even as a theory of personality, psychoanalysis is primarily an account of the processes and mechanisms of the mind, rather than an account of individual differences.

In addition to its breadth of focus, the psychoanalytic theory has many distinct components that have also been modified and explored by a range of skilled psychoanalysts, making it hard to integrate into a single unitary model of the mind since they are inter-connected in complex ways.

Freud’s views evolved continually throughout his long career in the collective result of his extensive writings as an elaborate system of personality development. Personality was described in terms of an energy system that seeks an equilibrium of forces. This homeostatic model of human personality was determined by the constant attempt to identify appropriate ways to discharge instinctual energies, which originate in the depths of the unconscious. The structure of personality, according to the psychoanalytic model consists of a dynamic interchange of activities energised by forces that are present in the person at birth. This homeostatic model was consistent with the prevailing views of 19th-century science, which saw the mechanical relations of physical events studied by physics as the term of scientific inquiry. Freud’s model for psychoanalysis translated physical stimuli to psychic energies or forces and retained an essentially mechanical description of how such forces interact.

As the writings on the dpurb.com website are the foundations for the Organic Theory of the mind, we are going to be focused not on the later structural model which repositioned the Unconscious, Conscious and Pre-Conscious across the Id, Ego and SuperEgo, but with the first topographic model (1900 – 1905) adopted by both Carl Jung and Jacques Lacan. This model, has been more influential and is more flexible in accommodating competing view points about the structure of mental life across individuals.

The topographic model refers to the levels or layers of mental life. Freud proposed that mental content – ideas, wishes, emotions, impulses, memories, and so on – can be located at one of the three levels: Conscious (later known as the Ego), Preconscious (SuperEgo), and Unconscious (Id). It is important however, to understand that Freud use these terms to describe degrees of awareness and unawareness, but also to refer to distinct mental systems with their own distinct laws of operation. Unconscious cognition is categorically different from Conscious cognition, in addition to operating on mental content that exists beneath awareness. To convey this point, the three levels of the topographic model was referred to as the ‘systems’ Cs., Pcs., and Ucs.

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The Conscious (which would later be known as Ego with a partial unconscious side, and also “Le Moi” in Lacanian Theory)

Consciousness is merely the proverbial ‘tip of the iceberg’ of mental activity. The contents of the Conscious are simply the small fraction of things that the person is currently paying attention to: objects perceived, events recalled, the stream of thought that we engage in as a running commentary on everyday life. [This is the main focus of most other branches of Psychology such as Biological Psychology and Cognitive Psychology]

 

The Preconscious (which would later be known as the Super-Ego, le « Grand Autre » in Lacanian Theory)

Of course, not all of all mental life happens under the spotlight of awareness and attention. There are many things to which we could readily pay attention to but do not, such as ideas or plans we have set aside or memories of what we were doing last week or yesterday. Without any great effort these things or events, which in the present are out of consciousness, can be made conscious. Those form the domain of the Preconscious.

The boundary between the Conscious (Ego) and the Preconscious (Super-Ego) is a permeable one. Thoughts, memories and perceptions can cross without great difficulty according to the momentary needs and intentions of the individual. They also share a common mode of cognition, which in psychoanalysis is known as the ‘secondary process’. Secondary process cognition is the sort of everyday, more or less rational thinking than generally obeys the laws of logic.

 

The Unconscious (which would later be known as the Id, L’inconscient or the « Ça » in Lacanian Theory)

The Unconscious (Id) is perhaps one of the most celebrated theoretical concepts in psychoanalysis’ legacy. However, Freud did not invent or discover the unconscious as is sometimes claimed – versions of the unconscious had been floating around intellectual circles for some time – but Freud gave it a much deeper theoretical analysis than anyone before him. Freud distinguished between mental contents and processes that are descriptively unconscious and those that are dynamically unconscious. The descriptively unconscious simply exists outside consciousness as a matter of fact, and therefore include Preconscious material that can become conscious if it is attended to. Freud’s crucial contribution was to argue that some thoughts, memories, wishes and mental processes are not only descriptively unconscious, but also cannot be made conscious because of a countervailing force keeps them out of awareness. In short, mental life that is dynamically unconscious is a subset of what is descriptively unconscious, one whose entry to consciousness is actively thwarted. The Freudian unconscious corresponds to the dynamic unconscious in this sense.

Freud held that the Unconscious contains a large but unacknowledged proportion of mental life that operates according to its own psychological laws. The barrier between the Unconscious (Id) and the Preconscious (SuperEgo) is much more fortified and difficult to penetrate than the border between the Preconscious (Super-Ego) and Conscious (Ego). In addition, it is policed by a mental function that Freud likened to a “censor”. The censor’s role is to determine whether the contents of the Unconscious would be threatening / objectionable or socially unacceptable to the person if they became conscious. If the censor judges them to be dangerous in this type, the person will experience anxiety without knowing what caused it. In this case, these thoughts become wishes and so on, and will be normally be repelled back into the Unconscious, in a process referred to asRepression” [it is fundamental and very important to understand that Repression is something else than a judgement which rejects and chooses, repression is unconscious]. Unconscious material, by Freud’s account, has an intrinsic force propelling it to become conscious. Consequently, repression required an active opposing force to resist it, just as effort is required to prevent a surf board made of white foam to rise to the surface when it is submerged in the ocean.

Under the constant pressure of Unconscious material bubbling towards the Preconscious, the censor cannot possibly bar entry to everything. Instead, it allows some Unconscious material to cross over the barrier after it has been transformed or disguised in some way so as to be less objectionable and more socially acceptable. This crossing might take the form of a relatively harmless impulsive behaviour, or in the form of private fantasy, the telling of a joke, or in a slip of the tongue, where the person says something ‘unintentionally’ that reveals to the trained eye and mind the repressed concerns and wishes [such as that of a psychoanalyst – as Jacques Lacan proposed: repression can take the form of a metaphor and the brilliant psychoanalyst must be able to decipher a chain of clues with a great deal of verbal dexterity where crossword puzzles may help in training]. Psychoanalytic training teaches how phenomena such as these can be interpreted, the process that involves uncovering the unconscious material that is concealed within their “disguises” [i.e. forms].

To Freud, dreams represent a particularly good example of the disguised expression of the Unconscious wishes. They offered, he wrote, “the royal road to the Unconscious”. One reason for this is that during sleep, the sensor relaxes and allows more repressed Unconscious material to cross the barrier. This material, transformed into a less threatening form by a process referred to as the “dream-work”, then takes the shape of a train of images in the peculiar form of consciousness that we call dreaming. It is believed, that each dream has a “latent content” of Unconscious wishes that is transformed into the “manifest content” of the experienced dream. This transformation has to allow the Unconscious wishes to be fulfilled while concealing the elements of threat they contain. If the latent content is not concealed sufficiently through the “dream-work” process, the sleeper will register the threat and be awoken [sometimes in shock and sweat]. To avoid this the dream-work may alter the identities of the people represented in a wish. For example if a person has an Unconscious wish to harm a loved one, the dream work might produce a dream in which the individual instead harms someone else or in which the loved one is harmed by another person. Neutralised in this way, the Unconscious wish finds conscious expression.

Dreams also showcase the distinct form of thinking that operates in the Unconscious.Primary processthinking, unlike the secondary process than governs the Conscious (Ego) and Preconscious (Super-Ego), shows no respect for the laws of logic and rationality. In primary process thinking, something can stand for something else, including its opposite, and can even represent two distinct things at once. Contradictory thoughts can coexist and there is not orderly sense of the passage of time or of causation. Basically, primary process thinking captures the magical, chaotic quality of many dreams, the mysterious images that seems somehow significant, the fractured storylines, the impossible and disconnected events. To Freud, dreams are not simply night-time curiosities, but reveal how the greater part of our mental life proceeds beneath the shallows of conscience.

 

Foundations of the later “Structural” model: concepts to consider and synthesise with the Topographic Model

We are now going to have a look at the later version of Freud’s psychoanalytic theory where the Unconscious [this time referred to as the Id] is still the fundamental concept, however decades later in 1923, another 3-way dissection of the mind was proposed. This time Freud called it the Psychic Apparatus and the 3-way dissection of the mind was defined in terms of distinct mental functions instead of levels of awareness and their associated processes. In original German, the terms das Es (Id), Ich (Ego) and Über-ich (Super-Ego) were used. As we take a look at these structures, it is important to remember that they were not proposed as real underlying entities, but rather as a sort of conceptual shorthand for talking about different kinds of mental processes. Our aim here is to synthesise the logical concepts of the Structural Model with the earlier Topographic Model of the Unconscious (Id), the Conscious (Ego) and the Preconscious (Super-Ego), however although it is convenient to talk about the Id, Ego and Super-Ego “doing” such-and-such or being “in charge of” so-and so, it is important to remember that they were not intended to refer to distinct sub-personalities within the individual.

Modèle_Structurel_Id(LeCa)_Ego(Moi)_SuperEgo(Surmoi)_IcebergModel_dpurb

The Id (Unconscious, das Es / Inconscient / Le Ça)

The Id [completely/dynamically unconscious] represents the part of the personality that is closely linked to the instinctual drives that are the fundamental sources of motivation in Freudian theory. According to Freud, these drives are chiefly sexual and aggressive in nature. On one hand we have the “life instincts” concerned with preserving life and binding together new “vital unities”, the foremost expression of this concern being loving sexual union. Opposed to these life instincts, on the other side, we have the set of “death instincts”, whose corresponding concern is with breaking down life and destroying connections, its goal is a state of entropy or nirvana, where there is a complete absence of any form of tension [motivation] – the most obvious form of these instincts were aggressiveness expressed inward towards the self or outward towards others. Freud proposed that the instinctual drives were powered by a reservoir of instinctual “psychic energy” grounded in basic biological processes. The sexual form of this energy was referred to as libido. Although Freud proposed that the unconscious Id is a biological underpinning, its contents are psychological phenomena such as wishes, ideas, intentions, and impulses. These phenomena are therefore sometimes described as “instinct- derivatives”. Some of these phenomena are innate, whereas others have been consigned to the Id by the process of repression. All of the Id’s contents, however are unconscious. Freud proposed that the Id operated according to what he called the “pleasure principle”. Simply stated, this principle states that the Id’s urges strives to obtain pleasure and avoid “unpleasure” without delay. Pleasure, in Freud’s understanding, represented a discharge of instinctual energy which is accompanied by a release of tension. In short, the Id strives to satisfy its drives enabling immediate, pleasurable release of instinctual energy. It is the most primitive and least accessible structure of personality. As originally described by Freud, the Id is psychic energy of an irrational nature and sexual character, which instinctually determines unconscious processes. The Id is not in contact with the environment, but rather relates to the other structures of personality that in turn must mediate between the Id’s instincts and the external world. Immune from reality and social convention, the Id is guided by the pleasure principle, seeking to gratify instinctual libidinal needs either directly, through a sexual experience, or indirectly, by dreaming or fantasizing. The latter, indirect gratification was called the primary process. The exact object of direct gratification in the pleasure principle is determined by the psychosexual stage of the individual’s development [as explained in 3rd part of the essay on The 3 Major Theories of Development].

 

The Ego (Conscious & partially unconscious, Ich / Le Moi)

The Ego, is another mental function and complicates this picture of immediate gratification. This “psychic agency” arises over the course of development as the child learns that it is often necessary and desirable to delay gratification. The bottle or breast does not always appear the instant that hunger is first experienced, and sometimes it is better to resist the urge to urinate at the bladder’s first bidding if one is to avoid the unpleasure of wet pants, embarrassment, and a parent’s howls of dismay. The Ego, often called the “executive” of personality because of its role in channeling Id energies into socially acceptable outlets [ego is believed to start developing between the ages of 1 and 2 as the child confronts the environment]. The Ego crystallises out this emerging capacity for delay, and in time becomes a restraint on the Id’s impatient striving for discharge. However, it cannot be an inflexible restraint. Its task is not to delay the fulfilment of wishes and impulses endlessly, but to determine when and how it would be most sensible or prudent to do so given the demands of the external environment at a particular time. It operates, that is, on the “Reality principle”, which simply requires that the Ego regulate the person’s behaviour in accordance with external conditions [at a given time or place according to certain rules or laws or conventions, and of course this changes as society redefines “reality” in terms of what it acceptable and not]. Freud emphasized that the Ego is not the dominant force in the personality [unlike Ego psychologists in the US has stated], although he believed it should strive to be. A famous statement of Freud regarding the goal of Psychoanalytic treatment is “Where Id was, there Ego shall be”. By his account, the Ego not only emerges out of the Id in the course of development – beforehand, the infant is pure Id – but it also derives all of its energy from the Id. Freud had a gift for metaphor, and he likened the Ego’s relation to the Id as a rider’s relation to a wilful horse. The horse supplies all of the pair’s force, but the rider may be able to channel it in a particular direction. Fortunately, this “rider” has a repertoire of skills at its disposal. Freud proposed that the Ego could employ a variety of “defence mechanism” in the service of the reality principle. These mechanisms come in a diverse range, and all represent operations that the Ego performs to deal with the threats to the rational expression of the person’s desires, whether from the Super-Ego or the external environment. These Ego defence mechanisms are common processes in everyday mental life, and many of them are carried out by the Ego unconsciously, showing that there is an unconscious part in the Ego. The Ego being governed by the reality principle, is aware of environmental demands and adjusts behaviour so that the instinctual pressures of the id are satisfied in acceptable ways, and the attainment of specific objects to reduce libidinal energy in socially appropriate ways was called the “secondary process” [the “primary process” being the Unconscious (Id)]. Some of the most well known defence mechanisms are denial, isolation of affect, projection, reaction formation, repression and sublimation.

 

The Super-Ego (Conscious & partially unconscious, Über-ich / Le Surmoi / L’Autre / Le Grand-Autre)

Finally, the differentiation of the structures of personality, called the Super-Ego, is believed to start appearing by the age of 5. In contrast to the Id and Ego, which are internal developments of personality, the Super-Ego is an external imposition. That is the Super-Ego is the incorporation of moral standards perceived by the Ego from some agent of authority in the environment, usually an assimilation of the parents’ views as the child develops – both positive and negative aspects of these standards. The Super-Ego’s emergence complicates the task of the Ego in regulating the expression of the Id’s impulses in response to demands and opportunities of the external environment. The Super-Ego represents an early form of conscience, an internalised set of moral values, standards, and ideals. These moral precepts are not the sort of flexible, evolving, reasoned, and discussable rules of conduct that we tend to imagine when we think of adult morality, however, instead they tend to be relatively harsh, absolute and punishing; adult morality as refracted through the immature and fearful mind of a child. The Super-Ego therefore represents the shrill voice of societal rules and restrictions, a voice that condemns and forbids many of the sexual and destructive wishes, impulses and thoughts that emerge from the Id. The positive moral code is the Ego ideal, i.e. a representation of behaviour for the individual to emulate. The conscience embodies the negative aspect of the Super-Ego, and determines which activities are to be taboo. Conduct that violates the dictates of the conscience produces “guilt” in healthy individuals. Hence, the Super-Ego and the Id are in direct conflict, leaving the Ego to mediate. The Ego now becomes the servant of three masters: the Id, the Super-Ego and the External Environment [Societal Rules]. It is now not enough to reconcile what is desired with what is possible under the circumstances because now the Ego also needs to take into consideration what is socially prohibited and impermissible. Instinctual drives must still be satisfied; which is a constant, however the Ego now attempts to satisfy them in a way that is flexibly “realistic” – that is, in the person’s best interests under current conditions – but also “socially” permitted. These prohibitions are often very unreasonable and inflexible, rejecting any expression of the drive with an unconditional “NO”, either because the moral structures of a particular “culture” are intrinsically rigid, atavistic or unsophisticated, or because the child’s internalisation of these structures is simply black-and-white, without any grey area to compromise for an adequate expression of the drive. Thus, the Super-Ego imposes a pattern of conduct that results in some degree of self-control through an internalised system of rewards and punishments.

Given the demands that it faces, the Ego can either find a way to express the Id’s desires successfully, or its attempts to arbitrate can fail. In this case, psychological trouble is likely to follow. If the Id wins the struggle, and the desire finds expression in a more-or-less unaltered and primitive form, the person may experience guilt or shame: the Super-Ego’s sign that it has been violated, and may also have to pay the price of a short-sighted, impulsive action. If on the other hand, the Super-Ego wins the struggle and dominates a person excessively, that individual may become overly rigid, rule-bound, uncreative, unquestioning, anxious and joyless. The forbidden desires may well go “underground” and manifest themselves in symptoms such as anxieties, compulsions or in occasional “out-of-character” impulsive behaviour or emotion.

 

Intrapsychic Conflict: the root of personality

The major motivational constructs of Freud’s theory of personality was derived from instincts, defined as biological forces that release mental energy. Hence, from the account of the Unconscious (Id), the Conscious [and partly unconscious, Ego) and the Preconscious (Super-Ego), it implies that conflict within the mind’s opposing forces is inevitable, because the demands of society – or “civilisation” – are generally opposed to our natural instincts and drives. Indeed, intrapsychic conflict is one of the fundamental and defining concepts of psychoanalysis. Conflict within the mind is at the root of personality structure, mental disorder, and most psychological phenomena [e.g. artistic expressions of various forms]. The goal of personality is to reduce the energy drive through some activity acceptable to the constraints of the Super-Ego [Preconscious].

Freud classed inborn instincts to life (eros) and death (thanatos) drives. Life instincts involve self-preservation and include hunger, sex and thirst. The libido is that specific form of energy through which life instincts arise in the Id. The death instinct (Thanatos) may be directed either inwards, as in suicide or masochism, or outwards, as in hate and aggression. The notion that personality equilibrium must be maintained by discharging energy in acceptable ways, leads to anxiety which plays a central role. Essentially the view is that anxiety is a diffuse fear in anticipation of unmet desires and future evils. Given the primitive character of Unconscious (Id) instincts, it is unlikely that primary goals are ever an acceptable means of drive reduction; rather they are apt to give rise to continual anxiety in personality. Freud described three general forms of anxiety.

(i) Reality (or Objective) Anxiety
(ii) Neurotic Anxiety
(iii) Moral Anxiety

Reality or objective anxiety, is a fear of the real environmental danger [e.g. heights, depth, fire, etc] with an obvious cause; such fear is appropriate as it has survival value for the organism. Neurotic anxiety comes about from the fear of potential punishment inherent in the goal of instinctual gratification. It is a fear of punishment for expressing impulsive desires. Finally, moral anxiety is the fear of the conscience through guilt or shame in healthy individuals. In order to cope with anxiety, the Ego develops defence mechanisms, which are elaborate, largely unconscious processes that allow a person to avoid unpleasantness and anxiety-provoking events. For example, an individual may avoid facing anxiety by self-denial, conversion [whereby the anxiety caused by repressed impulses and feelings are ‘converted’ into a physical complaint such as a cough or feelings of paralysis], or projection, or may repress thoughts that are a source of anxiety into the unconscious. Many defence mechanisms are described in the psychoanalytic literature, which generally agrees that although defence mechanisms are typical ways of handling anxiety and maintaining a sense of psychological stability, they must be recognised and controlled by the individual himself/herself for psychological health.

Denial Refusing to acknowledge that some unpleasant or threatening event has occurred; common in grief reactions
Isolation of Affect Mentally severing an idea from its threatening emotional associations so that it can be held without experiencing its unpleasantness; common in obsessional people
Projection Disavowing one’s impulses thoughts and attributing them to another person; common in paranoia
Reaction formation Unconsciously developing wishes or thoughts that are opposite to those that one finds undesirable in oneself; common in people with a rigid moral codes
Repression Repelling threatening thoughts from consciousness, motivated forgetting; common in post-traumatic reactions
Sublimation Unconsciously deflecting sexual aggressive impulses towards different, socially acceptable expressions; central to artistic creation and sports.

Table 1: A List of The Most Common Defence Mechanisms

Freud placed great emphasis on the development of the child because he was convinced that neurotic disturbances manifested by his adult patients had origins in childhood experiences. And as the last model proposed by Freud, the Genetic Model, explains, the psychosexual stages are characterised by different sources of primary gratification determined by the pleasure principle. Freud basically wrote that the child is essentially autoerotic. The genetic model has been previously described in the 3rd section of the essay, The 3 Major Theories of Childhood Development. [Please refer for more details]

However, the genetic model in psychoanalysis has been extensively revised and many of the concepts have given way to other theories [such as the Bowlby’s Theory of Attachment] nowadays that consider other sides in the development of personality. Other theories of peronality have also shown how personality continues to evolve and only stabilises around the age of 30. However, the genetic model of Freud laid the groundwork for other theorist such as John Bowlby and Mary Ainsworth who based their guiding principles to uncover the theory of attachment on pre-oedipal developments first mentioned by Sigmund Freud. These attachment types have been discussed in the Essay, The 3 Major Theories of Childhood Development, and although it may not be completely true for all people, the logic behind the psychosexual stages should always be considered to some extend when analysing clients along with attachment types – not to forget to assess the self-reflective abilities of the person, since this has been proven to have more impact on self-adjustment related to adult personality, emotional intelligence and attachment types.

 

The Relationship between the Topographic Model and the Structural Model

It is important to assimilate the knowledge from the structural model and synthesise them with the topographic model. It can be seen that although the later model is conceptually distinct from the first model, they do map onto one another to some degree. The content of the Id, of course, lies firmly within the Unconscious, and is forbidden from entry to the consciousness unless disguised in the form of dreams, slips of the tongue, symptoms, and so on. However the Ego is not completely conscious unlike many ego psychologist may claim along with cognitive psychologist, as it has a strong Unconscious component, given that a great deal of psychological defence mechanisms are conducted instantly out of awareness, and hence is sometimes inaccessible to introspection by the patient – hence requiring a skilled psychoanalyst to guide therapy and treatment. The Super-Ego also has an Unconscious fraction, reflecting as it does and often “primitive”, and irrationally punishing through rigid morality – at least as much as it reflects our reasoned beliefs and principles. Although many concepts have been revised and alternative treatments relating to mental illness have also been devised by other schools of thought in psychology, the sheer complexity and uniqueness of the psychoanalytic system has formed a remarkable achievement. Indeed, Freud even had to invent new terminology to express his thoughts, and these terms have become an accepted part of our vocabulary.

Psychisme: Les théories de Freud ont-elles évolué? (2013)

 

Psychoanalytic Evidence: From the perspective of Empirical Methodology (Mainstream Science)

Freud ardently believed along with all good psychoanalysts that psychoanalysis is a science, not an empirical science, but a science of the mind that slices not with blades or questionnaires, but with concepts through the linguistic and philosophical realm of a patients subjective reality. It is also fair to consider that Freud himself was an accomplished biological scientist before he developed psychoanalytic theories. Biological ideas are interwoven in his work, as is his concepts of drive, instinct, and psychic energy. Nevertheless, the methods that he used to obtain evidence for the psychoanalytic theory were very different from the reductionist and empirical methods used by the government institutions, laboratory scientists or the statistical psychologists with their quantified questionnaires exploring basic “traits”. As an anatomist and physiologist, Freud made systematic observations of living and dead organisms, and conducted controlled empirical experiments. Hence, he must have come to the same conclusion as ourselves, which is, mental life cannot be fully explained by the mechanical explanations, although a lot can be learnt from understanding the physiology of the brain, but the “software” itself, that generates the mind, is an entity that empirical science comes short in terms of its methodologies. Hence, as a psychoanalyst, Freud introspected and speculated about his own mental life, and listened closely to what his patients told him during sessions of psychoanalytic therapy. It is quite clear, that dissecting an eel is completely different from dissecting a personality with all its complexities, and that observing the stream of one’s consciousness or another’s speech is very different from conducting a controlled experiment with observable variables. So, psychoanalytic evidence is clearly unlike the evidence on which most “hard physical sciences” are based.

However, it is important to understand that the critique of psychoanalysis from the methodology of empirical science may not be rational. Because psychoanalysis was never intended to be a mechanical science, although it learns from neuroscience and cognitive-psychology of certain very basic aspects of the physiology of the brain and its functions. These questions about Empirically Supported Treatment (EST) came to the forefront of psychotherapy literature in 1993, when Division 12 of the American Psychological Association worked to publish a list of criteria for what constitutes EST (Chambless, et al., 1996; Task Force on Promotion and Dissemination of Psychological Procedures, 1995; Taskforce on Psychological Intervention Guidelines, 1995). A list of treatments were published that we empirically supported and very few psychodynamic treatments were included, nor were interpersonal or humanistic therapy included. Not surprisingly, these guidelines and list became anything but unifying for psychotherapists and psychotherapy researchers.

Westen, Novotny and Thompson-Brenner (2004) made some important critiques of the literature on ESTs. They noted that ESTs are often designed for a single, Axis I disorder, and patients are screened to maximise their homogeneity and to minimise their diagnostic comorbidity. Treatments are manualised and brief, and outcomes are assessed often by reductions in the primary symptom reduction for that particular disorder. Westen et al. suggested that EST researchers always tend to assume the following:

  • Psychopathology is highly malleable
  • Most patients can be treated for a single problem or disorder
  • Psychiatric disorders can be treated without much attention to underlying personality factors
  • Experimental methodology used to develop ESTs has ecological validity in clinical practice

Westen et al. (2004) basically contended that these assumptions are not valid, not to say wrong. There is considerable diagnostic comorbidity, making most patients ineligible to participate in EST research trials. There also is considerable stability of psychopathology of psychiatric symptoms, even after “successful” completion of EST. And clinicians of all theoretical orientations see patients well beyong the time allotted in treatment manuals (see Morrison, Bradley, & Westen, 2003; Thompson-Brenner, Glass, & Westen, 2003; Westen & Morrison, 2001 for an excellent review of these issues).

Norcross (2002a) offered an additional perspective on why the EST literature has been so controversial. First, he explained that EST research rarely addresses the fact “that the therapist is a person, however much he may strive to make himself an instrument of the patient’s treatment” (Orlinsky & Howard, 1977, p.567 as cited by Norcross 2002a). This idea has been demonstrate very well in empirical literature. For example, Wampold (2001) concluded in a meta-analysis of psychotherapy studies that the qualities of the therapist play a much stronger role in the outcome of treatment that does the treatment itself. Second, Norcross stated that therapy research has savagely neglected the important question of studying the therapy relationship. Instead, the focus has been more on the application and mastery of a technique (not a relationship). Third, who the patient is affects treatment outcome. As attention has been directed towards the study and implementation of psychotherapy techniques to different categories of disorders, small attention has been given to the patient characteristics that affect outcome, such as comorbid conditions, capacity for insight, and a history of interpersonal relatedness.

Psychoanalytic and psychodynamic therapies certainly are related to these issues. Analytic and Dynamic models of therapy are very focused on the behaviour and qualities of the therapist, with special attention to issues of the therapeutic alliance, neutrality, transference, and countertransference.

Freud's Couch at Freud Museum London

The couch that started everything: Freud’s psychoanalytic couch at the Freud Museum in London

It is important to also consider that one’s training in how to conduct psychoanalytic or psychodynamic psychotherapy is focused on how therapists present themselves and how patients respond to this. Such a focus automatically puts the therapeutic alliance at the centre of attention, something that has taken on more interest over the years (Fairbairn, 1952; Greenberg, 1986, 2001a; Pine, 1998; Stolorow, Atwood & Brandchaft, 1994; Wallerstein, 2002). Psychoanalysts have also recognised that the personality and qualities of the patient affect how therapy should be conducted (e.g., Gabbard, 2000, 2004); that is, one approach to working with patients does not fit all patients. Furthermore, many psychotherapists have been reluctant to allow their therapy relationships to be subject to empirical investigation (Bornstein, 2005), as a form of respect for the privacy of their clients, making it very hard to provide more objective data that the support the validity of psychoanalysis. In contrast, other schools of thoughts derived from the behavioural school and the medical fields have very willingly offered their data for empirical investigations.

Often accompanying this philosophical criticism regarding scientific testability is a factual criticism that psychoanalysts have seldom tried to test their theories scientifically. This criticism may have some truth to it, however many psychoanalysts have responded to the call for more scientific inquiry by asserting that it is unnecessary and that clinical evidence of the treatments curing mental illness of various types is quite sufficient.

FIGURE B - SUCESS RATES WITH ADULTS & CHILDREN

Success Rates of Psychotherapy with adults and children, and Therapy from other schools of thought [traditions] based on Effect Sizes from Meta-analyses / Source: dpurb.com

Other psychoanalysts have argued that scientific support for their theories is irrelevant. Psychoanalysis, they suggest, is not an empirical science, but a science of subjective experience and linguistic dissection, so it is inappropriate to judge it by the mainstream reductionist empirical scientific standards of modern day academia.

Many see psychoanalysis as a “hermeneutic” discipline, an approach to interpretation which is rather like a school of literary criticism or biblical scholarship. To them, psychoanalytic theory is a way to decipher mental life, an interpretative technique for uncovering meaning. Its goal, they say, is to understand psychological phenomena in terms of their underlying reasons rather than explaining them as objective science in terms of causes. Some have gone so far as to suggest that the goal of psychoanalytic understanding is not to ascertain literal or scientific truth – for example, what “truly happened in a person’s past to make them the way they are today” – but instead to formulate “narrative truth”, a story that gives coherent meaning to the person’s experiences [from their perspective in terms of what matters to them] (Spence, 1980).

LePromeneurSolitaire-dpurb-com-1200

Photographie: Danny D’Purb © 2018

It would also be fair to acknowledge that there is something quite “special” about psychoanalytic evidence, for all its empirical flaws. A completed psychoanalytic treatment may sometimes [depending on the type of patient] occupy four or five sessions each week over a period of several years, amounting to perhaps 1000 hours in which the analyst listens closely to the patient’s innermost thoughts. These thoughts, often too intimate and raw to be shared even with loved ones, range widely over the patient’s personal history and lived experiences. They are recounted in a wide variety of mood-states and frames of mind. These millions of spoken words and feelings may not represent the kind of systematically and objectively collected data on which the scientific theory of personality [that the hardcore empiricist loves] can easily be built. However, it is hard to declare that the analyst does not understand the patient’s personality better than someone who might interpret the patient’s responses, dashed off in a matter of minutes, to a trait questionnaire.

Indeed, there is something valuable about psychanalytic evidence, but it is very hard to build an empirical theory out of it since we are not dealing with matters of hard sciences [e.g. biology, medecine, physics, chemistry, astrophysics, material science, astronomy, etc], but the mind of human beings that embodies their whole existence and worlds.

 

Empirical Evidence for the Existence of Unconscious Processes

More and more psychoanalytic thinkers and sympathisers are starting to find creative ways to test psychoanalytic hypotheses in rigorous empiricistic ways to conform with academic science, despite all the difficulties that this involves. This research is now very extensive, and therefore difficult to summarise. However, two very broad conclusions can be drawn from it. First, specific Freudian claims typically fail to receive experimental support but do work in treating mentally ill patients in clinical practice. For example, repression, castration anxiety and penis envy [although Adler suggested that this should be expressed symbolically as women’s frustration at not being able to match male dominance in society] cannot be demonstrated through the methods used for empirical experiments in a laboratory. Dreaming does not seem to preserve sleep by disguising latent wishes, and there is very little empirical evidence to back up the theory of Psychosexual stages, although it influenced the Theories of Attachment devised by John Bowlby. However, more general Freudian concepts have often received a good deal of scientific support.

There is today, plenty of evidence to suggest the existence of unconscious mental processes, for the existence of conflict between these processes and conscious cognition, and for the existence of processes resembling some of the defence mechanisms. Two illustrative studies can support his work. First, Fazio, Jackson, Dunton and Williams (1995) found that people who sincerely profess to having absolutely no racial prejudice can be shown to associate negative attributes with Black faces more than White faces in a laboratory task. This finding which has been replicated countless times by social cognition researchers, shows that the conscious attitudes of individuals may conflict with their “implicit” attitudes [unconscious]. Second, Adams, Wright and Lohr (1996) hooked male subjects up to a daunting instrument called the penis plethysmograph, which measures sexual arousal by gauging penile circumference. It was found that men who reported strong anti-gay (homophobic) attitudes demonstrated an increased arousal when shown videos of homosexual acts, whereas non-homophobic men did not. This finding seems to reveal some form of defence mechanism consistent with the psychoanalytic view that homophobia is a reaction formation against homoerotic desires. However, none of these illustrative studies can be considered as completely conclusive, and all have been controversial and subjected to various interpretations. For example, anxiety, shock, or anger rather than sexual arousal may have caused the increased penile blood flow of Adams et al.’s homophobic subjects.

These experiments prove that with enough creative ingenuity, some psychanalytic propositions can be scientifically tested. Doing so should contribute to the important task of sifting what is worth retaining in psychoanalytic theory for strict empiricists of the hard sciences.

 

Unconscious Processes: Integrating Cognitive Neuroscience and Psychodynamic Theory

In various ways, the evidence for the existence of mental processes that are outside of direct conscious awareness are apparent in every scenarios of life. Here are some examples:

  1. We sometimes cannot remember the name of a particular person of importance, only to be able to recall it hours or days later at a time and place when knowing the name is not required
  2. Despite one’s intention to offer some control over the process, dreaming appears to occur at its own timing and pace.
  3. On September 11, 2001, and the days following, many Americans watched hours of news report focussed on the same attacks on the United States. Although deeply upset by the contents, many individuals could not stop themselves from watching these videos, saying that it was as if something in them drew them to reports in spite of conscious awareness of disbelief and outrage
  4. Many patients who seek psychotherapy are unable to stop unwanted behaviours or interpersonal problems, despite conscious awareness of their harmfulness to them and their life. These problems range from relatively simple [e.g. drinking too much alcohol] to relatively complex [e.g. placing oneself in situations in which one is often taken advantage of or obsessing about one’s body image if certain kinds of fattening foods are consumed].

Other examples are evident too, simple exercises that can be easily performed. For example, consider when 3 lines are drawn in the shape of a triangle with the ends of each line however, not touching one another, leaving a small gap between all their extremities. We can come to realise that, depending on the space between the lines, the image is instantly perceived as a triangle by the individual, a triangle with missing edges; 3 lines that are coming together like a triangle, or just 3 lines at different angles.

When taking into consideration perceptual phenomena such as this [i.e. an example of the Gestalt principle of closure], it is evident that the mind does the following very quickly, without conscious awareness of how the process occurs, yet meaning and understanding are formed.

  • Takes in sensory information
  • Determines what the information is
  • Assembles the information in such a way that a percept or concept is formed
  • The percept or concept is “perceived” and “understood”

The evidence for the existence of unconscious processes is widely known in cognitive psychology. In a seminal paper in the American Psychologist, Shevrin and Dickman (1980) demonstrated how conclusions from the studies of selective attention, cortical evoked potentials, and subliminal perception provide support for the concept of an unconscious mind and posit that “no psychological model that seeks to explain how human beings know, learn, or behave can ignore the concept of unconscious psychological processes” (p. 432). They also noted that the initial stage for processing all stimuli occurs outside of consciousness and that it affects what is known consciously. This early stage is different in how it operates from conscious cognition, and conscious cognition necessarily occurs after considerable preconscious processing. Years, later, their conclusions and ideas appear to be no less true.

 

Empirical and Cases Studies Demonstrating Unconscious Processes

In studies of subliminal perception, which began in 1950s, the processing of unperceivable stimuli and its effect on behaviour has provided interesting results about the unconscious mind. Shevrin and Fisher (1967) subliminally presented participants with a picture of a pen and knee just prior to falling asleep. When they awoke from rapid eye movement (REM; dream stage) sleep, participants’ associations to their dreams were of a pen or knee or included less rational kinds of associations (a finding that had been well demonstrated in past sleep studies). These included words that sound like pen or knee, such as pennant, hen, or neither. In contrast, those who awoke during non-REM sleep, which had been associated with few dreams or dreams that were more rational, had associations such as penny (pen + knee) or related words, such as nickel and dime.

Shevrin (2006) noted that this study demonstrated that 2 levels of unconscious processing – irrational and rational – were taking place. He deduced that once inhibitions [e.g. defences] weaken – in this case, being awakened from sleep – more rational processes overtaken by irrational ones. Surprisingly, the more irrational process observed in this study produced content similar to what was found in severe types of psychopathology: repetition and clanging. In a follow-up study with the same methodology, Shevrin (1973) presented participants with the same stimuli, this time while they were fully awake and more proximal  to entering the sleep state. Again, they found a similar pattern of results in which the type of associations produced varied depending on when participants were awakened.

Even more interesting results were described by Shevrin and colleagues (Shevrin, 1988; Shevrin, Bond, Brakel, Hertel & Williams, 1996; Shevrin et al., 1992), who set out to demonstrate that unconscious and conscious processes operate differently. In these studies, patients were selected who had either pathological phobic reactions or extended grief. They were then assessed via interview, and 4 psychoanalysts listened to the interviews carefully. By way of consensus, the psychoanalyst researchers derived a conceptualisation of the core conflicts for each patient; then went on to select the patients’ words that they believed captured the patients’ conscious experience of the symptoms and words that represented unconscious conflict. These words along with unrelated words were then presented both subliminally and supraliminally to the patients, who were then asked to classify them as belonging together. Using event-related potentials to detect patients’ ability to classify or respond to words in similar ways, the researchers found that words representing unconscious conflicts were correctly classified only when presented subliminally and that the reverse was true for supraliminally presented words; they were correctly classified only when presented supraliminally. Here, we find some sense to Lacan’s deductions regarding the unconscious being structured like language and the linguistic dexterity that psychoanalyst should be able to handle to decipher and understand the fullness of the patient’s mind [conscious and unconscious].

Shevrin (1996) concluded, “…When [these studies are] taken in combination, [they] show that unconscious psychological causes affect consciousness in a qualitatively different way… and that unconscious conflict has an existence independent of the of the psychoanalyst’s inferences from conscious manifestations, an independence supported by brain correlates” (p. 591, italics in original). Shevrin also published reviews of research showing an association between subliminal perception and dreaming (Shevrin, 1986) and subliminal perception and repression (Shevrin, 1990).

In a more recent meta-analysis from more than 100 studies of subliminal perception, Weinberger and Hardaway (1990) found that psychodynamic material presented subliminally had a noticeable and predictable effect on behaviour, suggesting very clearly that unconscious processes affect overt behaviour. For instance, studies by Silverman and colleagues (Silverman, 1983, 1986; Silverman, Bronstein & Mendelsohn, 1976; Silverman, Kwawer, Wolitzky & Coron, 1973; Silverman, Lachman & Milich, 1982; Silverman, Ross, Adler & Lustig, 1978) found that subliminally presented messages of Oedipal content (e.g., “Beating dad is okay”) to male participants yielded more competitiveness in a subsequent dart-throwing game than non-Oedipal messages. [Note: Freud proposed that at the Oedipal stage, a competition between father/son and daughter/mother takes place, before it is resolved in the child gradually adopting the same-sex parent’s values as his/her own in the development of an early form of Conscience (Super-Ego/Preconscious)]

Bradley and colleagues (Bradley, Mogg & Millar, 1996; Bradley, Mogg and Williams, 1994, 1995) performed a series of studies in which words related to depression (e.g. misery, grief, despair) are subliminally presented to individuals who fall into 3 groups: those meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for major depression, those with subclinical levels of depression and those operating as controls. They consistently found that on implicit memory tests, depressed and subclinically depressed individuals correctly identity words related to depression more often than those who are not depressed. Although their findings have not been consistently replicated for patients suffering with anxiety, studies with depressive patients suggest that a level of processing occurs below conscious awareness that increases individuals’ awareness of and identification of depressive material. Clinically, it would suggest that to effectively treat and manage depression, addressing issues related to unconscious sensitivity to depressive material is very important. Given the relatively high relapse rates for depression and other disorders that are treated with methods focussing more on conscious awareness – via cognitive and behavioural therapies (Westen & Morrison, 2001) – it seems that attention to unconscious processes has the potential to effectively address some depressive disorders.

Eagle (1987) provided support for the notion of unconscious processing in studies of perceptual illusions and dichotic listening, a type of selective attention task. For instance, in the Ames room experiment (Ittleson & Kilpatrick, 1951), the ceiling and floor were not parallel, and the 2 subjects stood either towards the front or back of the room. This led perceivers to believe that the people very different in size , despite the fact that they were not. In the dichotic listening task (Lewis, 1970), individuals heard 2 different messages in each ear but were trained to attend to just one of those messages. When asked to repeat what was heard in the trained ear, individuals had less of a reaction time in producing the words when the words in the other ear were semantically similar [the meaning was synonymous / it meant the same thing]. This means that, there was a facilitative effect on performance when a semantically similar word was processed (unconsciously) in the “unattended” ear.

Further studies of patients who have experienced brain injuries provide interesting clinical observations that support the presence of unconscious processes. Milner, Corkin and Teuber (1968) reported the famous case of a patient known as H.M., who had undergone surgery on his medial temporal lobes to control very severe seizures. We nowadays know that just below the this part of the cortex lies the hippocampus, which is considered as an important anatomical locus for learning new information and storing it in working and long-term memory. Because of the damage done to the medial temporal lobes by the procedure, H.M. failed to remember anything that was new to him past surgery. H.M. however could remember information if he rehearsed it, although it was quickly lost if he was interrupted.

One interesting consequence of this procedure was that H.M. appeared not to have lost all “affective” components of certain experiences. For instance, H.M. had the occasion to visit his mother, who was hospitalised. After leaving the hospital, he had no recollection of visiting her, although he had the idea that something may be wrong with her. H.M. experienced other events like this, demonstrating well that implicit learning was still occurring for “affectively charged” situations and that the unconscious effects of this learning could be identified in everyday life.

Later studies of unconscious affective processing have suggested that there are at least 2 neural pathways that process affective information (LeDoux, 1989, 1995, as cited in Westen, 1999). One of these pathways originates in the thalamus and transmit sensory information to other brain regions, whereby emotional meaning is attached to the information. The other pathway, also originating in the thalamus, sends the sensory information to the cortex, where higher levels of emotional processing and emotional meaning are executed.

Mark Solms has reported some exciting work on the effects of unconscious processes on commonly observed clinical syndromes (e.g., Solms, 2000a, 2000b, 2001, 2002, 2004). Solms has taken a very active role in recent times in integrating the findings of neuroscience and psychoanalysis, which has created a relatively new discipline of study known as neuro-psychoanalysis. An interesting set of case of studies has been provided (Solms, 2000a) on patients who have experienced a strike on the right temporal lobe in the region, where the middle cerebral artery lies. In these case studies, psychoanalytic theory and treatment is integrated into the neurological understanding of the deficits the patients are experiencing.

Right hemisphere syndrome is a neurological disorder consisting of 3 major symptoms: ansognosia, neglect and spatial perception and cognition deficits. Anosognosia is the indifference or outright denial of an illness, which in the present case was the loss of the use of the patient’s left arm and side. Neglect occurs when patients ignore their paralysed limb and side. Patients often feel disgust when they are compelled to attend to the left side of the body, sometimes experiencing a sense of revulsion.

The spatial and cognitive deficits observed consist of defective facial recognition, imperceptions of facial emotion, environmental disorientation, and various kinds of apraxia [the inability to complete an activity involving muscle movement]. There are various theories about the emotional deficit in patients with right hemisphere syndrome. One theory suggests that the stroke affects attentional arousal that is mediated through activity in the right perisylvian region of the temporal lobe, which consequently gives rise to anosognosia and neglect. Another theory has focused on the fact that the left hemisphere is more involved with positive emotional processing and the right with more negative emotional processing. Since, the right hemisphere is damaged in this case, anosognosia and neglect occur because there is little to no processing of negative effect in the right hemisphere. A final theory states that it is the right hemisphere that is dominant for the perceptual representation of bodily states, which include more somatic or visceral perceptions. When this part of the brain is damaged or compromised, the bran can only rely on past somatosensory representations of bodily states, which provide the patient that there is no deficit or problem.

Solms (2000a) described Mr.C., a 59-year-old engineer who experienced right hemisphere syndrome after complications from a mild stroke. Only part of the visual field of the patient was remaining and he would not attempt to compensate for it [i.e. neglect], and he also ignored sensory stimulation that occurred on the left side of his body [anosodiaphoria]. He ignored and minimised his paralysed left arm, referring to it as being “like a dead piece of meat, but not it’s just a little bit lame and lazy” (p.71). Other deficits existed due to right parietal damage.

Mr.C. was “aloof, imperious and egocentric” (Solms, 2000a, p.72). He seemed unconcerned about others and would sit blankly at times staring into space. However, on occasion he would burst into tears or look as if this were the case. These periods however, were brief yet stood in stark contrast to the emotional coldness that he often presented with. During one physical therapy session, Mr. C. was making very little progress in learning how to walk. The physiotherapist reported to the treating psychologist that Mr. C. seemed “indifferent to the errors he was making, and he simply ignored her when she pointed them out to him” (p.74). In a session next day, Mr. C. told the psychologist that the physiotherapist indicated that he had been making mistakes, sounding as if he was confession something. Then, he said that another therapist had asked him to do some activities with blocks but that he could not do it. At this point, the therapist replied to Mr. C.:

 

“…it was difficult for him to acknowledge the problems his stroke had left him with, but it seemed that he was now more able to see them. Mr.C., carried on… [saying] his physiotherapy was “okay” but that his arm had not progressed to the degree that he required. Then, at this point, he suddenly  withdrew from conversing… and began to exercise his left hand and arm with the right one. [The therapist] commented that is seemed as if he could not bear the wait, and wanted his arm to be completely better instantly… [He replied] “I just don’t want my left arm to get weak from non-use.” [The therapist then replied] perhaps it was too painful for him to acknowledge what he was on the verge of recognising a moment earlier – namely that his arm really was completely paralysed – and that the question of whether it would recover or not was largely beyond his control. This comment provoked an instantaneous crumpling of his face and a burst of painful emotion accompanied by pre-tearfulness. [Turning to the therapist] he said in desperation “but look at my arm [pointing to his left arm] – what am I going to do if it doesn’t recover? (pp. 74-75)

 

Solms (2000a) noted that this case demonstrates how unconscious material that was too painful to acknowledge was accessed through careful interpretations. Furthermore, the case example controverts the theory that these patients lack negative emotions or have no awareness of their bodies and their deficits. In Mr. C’s case, it is clear that implicit processes were at work and that the emotional response originated out of the complex, associative networks were formed by this patient’s unconscious processing of the painful loss of his bodily integrity.

Transference phenomena can also be better understood in the light of recent findings in cognitive psychology. To understand transference phenomena, Westen and Gabbard (2002b, pp. 103-104) highlighted important ideas in recent studies of cognitive processing.

  1. More representations consist of memory traces that are multimodal, which include semantic, sensory and emotional components.
  2. Representations of self and other exist as potentials for activation. Because there are potentials, they are subject to modification, which will interact with new knowledge, further developing the self and other representations.
  3. Memory networks consist of semantic, episodic and procedural knowledge, along with differing affects and motives.
  4. Unconscious procedures to manage emotions are defences and may be triggered outside of awareness. Co-occurring motives and affects may also be activated, such that the person may not be aware of either one or the defence being used.
  5. Conscious representation are some of many representations that get activated. Consciousness is a serial processing system, whereas multiple parallel processes get activated that are not available to consciousness.

As may be observed in these principles, Westen and Gabbard (2002b) suggested that transference phenomena represent a dynamic, ongoing process that occurs at the conscious and unconscious level. Because multiple cognitive events occur at one time, transference phenomena can be highly complex phenomena and can represent one of many possible reactions to the therapist, as well as other meaningful individuals in the patient’s life. In fact, multiple transferences can occur. For instance, a patient may feel particularly challenged by his work and may experience some feedback from his female supervisor about his recent difficulties with his job. Suppose the patient’s mother took great strides to help him whenever he felt frustrated in his school activities or work, such that he came to unconsciously expect her to provide assistance during challenging times. At work the patient may have experienced the supervisor’s comments as an invitation for help and assistance. Should no help be forthcoming, the patient would become irritated and disappointed with such a difficult supervisor. Likewise, suppose that this patient’s father was unavailable to help him. He may have to come to view male authorities as uncaring and disinterested in his plight. Thus, in his present treatment, the patient may find himself feeling scared and anxious towards his male therapist when talking about his recent disappointment with the supervisor. An exploration of his interaction with his supervisor may elicit anxiety in the patient towards his therapist whom he experiences as a disinterested and uncaring male. Likewise, he may feel very frustrated towards the therapist  who is not willing to tell him how to manage his interactions with his supervisor, reflecting a maternal transference to the therapist who unconsciously should be offering help and assistance quickly and without much effort on the patient’s part.

 

The Psychoanalytic Account of Motivation

The account of human motivation, resting on sexual and death instincts, has been a big talking point for critics of psychoanalysis from the very beginning. Jung’s departure from the psychoanalytic movement was largely caused over disagreements over the motivational concepts. Jung questioned the centrality of sexuality and argued the importance of spiritual motives. Alfred Adler on the other hand proposed a basic desire for social superiority and a “will to power”. Later writers within the psychoanalytic tradition also sought to expand the theory of motivation to include drives for mastery and competence, and for interpersonal relatedness.

In general, there has always been 2 major issues, the first is whether the sexual and death instinct are plausible sources of human motivation. Second, whether they are sufficient explanations of motivation, or whether additional motives that are not reducible to these drives are needed.

With respect to the first issue, it may be hard to deny [from a universal and organic standpoint] that sexual wishes and drives are powerful sources of motivation, especially if we include “sexual” desires as a part of loving relationships and for bodily pleasure. From a biological and evolutionary perspective it could not be otherwise, since reproductive success is the basic currency of individual genetic fitness, not to mention species survival [in all species including primates and mammals].

From this perspective, the psychoanalytic emphasis on sexual drives – an emphasis shared by no other personality theory – is a very strong point of the psychoanalytic theory, even if we are allowed to disagree and investigate some particular claims that may not apply to some individuals regarding the effects of the Psychosexual stages in childhood as proposed by Freud [which inspired John Bowlby’s Theory of Attachment], or discuss the other drives that are non-sexual [e.g. Romantic love and its expressions].

272 Nat Museum of Women in Art 215_1000_dpurb

From the same evolution standpoint, a death instinct directed inwards towards self-destruction is questionable. However, this negative judgement on the death instinct, which is shared by many contemporary psychoanalysts, does not mean that we need to dispense with the idea of aggressive drives. Aggressiveness could be theorised not as a form of self-destructiveness, but rather as a way to strive for social dominance [among a particular frame, circle or group], i.e. to fend off “attackers” in defence of one’s own “territorial grounds” or to assert one’s personal choice or interest.

The second issue is whether sexual and perhaps aggressive drives are broad enough to capture the full range of human motivations. The answer, is clearly not. Since, we also have drives for achievement, approval, non-sexual relatedness, creativity, self-esteem, and so on? The other question is biologically-based motives that “push” us towards certain kinds of behaviour enough? Do future-oriented motivational concepts, like goals and personal ideals not “pull” us towards desirable endpoints? When these questions are raised, basic Freudian account of motivation may seem limited in their scope, leaving out motives that are socially shaped or personally determined. However, the issue is not so easily resolved, since psychoanalysts may agree that motivations beyond the instinctual drives are required to describe how our behaviour is guided, however it may still be argued that all these motivations are simply multiple layers of the very same instinctual drives. For example, achievement striving could be described psychoanalytically as a socially shaped motive that is underpinned and powered by aggressive urges [that are applied in different forms to achieve our goals, i.e. not in a physically violent manner, but competitively in multiple sophisticated social ways]. On the same note, creativity might be understood as a sublimated expression of our sexual drives [e.g. artistic creations], based on some unconscious desire for unifying and making connections that Freud saw as the hallmark of life instincts.

Victor Hugo La Musique

Traduction(EN): « What we could not say and what we could not silence, music expresses. » -Victor Hugo (1802 – 1885)

However, even if the claim that human motivation is ultimately based on a few instinctual drives that govern all living organism, it would still be more enlightening and accurate to patients to describe their motivation in a more complex way, i.e. expressed to meet the sophisticated and multi-layered human societies we live in. So, in the end there is no objective or empirical way to establish the question of motivation with a clear “true or false” – we will have to use logical reasoning and theories about what drives “life” forward.

Documentaire: L’invention de la Psychanalyse (1997)

 

The 2 Major Disciples of Freudian Theory: Carl Jung and Jacques Lacan

The psychoanalytic movement was largely the invention of Sigmund Freud, and his influence far exceeds that of his early followers who subsequently tried to modify psychoanalysis. The major principles of psychoanalysis were redefined and reinterpreted until by 1930 the movement was fragmented into competing views. Nevertheless, those writers were departed from Freud’s speculation retain the basic model of psychoanalysis that conceived of personality in terms of an energy reduction system with three levels of awareness that is the conscious [that contains the Ego], preconscious [that holds the Super-Ego] and the unconscious [the wild Id]. The psychoanalytic movement has been very active since Freud’s death in 1939, and has led to many new theoretical developments influencing all schools of psychology rather than standing still as we have just seen regarding the reconciliation of some fundamental concepts with Cognitive psychology and Neurosciences.

 

Carl Jung (1875 – 1961)

Carl Jung

One of the most fascinating and complicated scholars of this century, Carl Jung (1875 – 1961) was born to a poor family in a northern Swiss village. He managed to gain entrance to the University of Basel and received a doctorate in medicine in 1900. Jung spent most of the rest of his life in Zürich, teaching, writing and working with patients. After reading The Interpretation of Dreams in 1900, Jung began corresponding with Freud and finally met him in 1907. Eventually he accompanied Freud to America in 1909, where he also lectured and introduced his own work to American audiences. However, Jung began to apply psychoanalytic insights to ancient myths and legends in search for the key to the nature of human psyche. Such independent thinking did not meet with Freud’s approval, and there is also some speculation that the Jung made a critical analysis of Freud’s personal life that may have contributed to tensions between them. Freud secured the post of the first president of the International Psychoanalytic Association for Jung in 1911, but by this time their rift was beyond healing. Finally, in 1914, Jung withdrew from the Association and severed all interactions with Freud due to the over-emphasis of the defining stages of infant sexuality among other aspects of pure Freudian theory.  Jung continued his own interpretations of psychoanalysis and made several expeditions to study primitive societies in Western United States, Africa, Australia and Central America. His prolific writings on subjects ranging from anthropology to religion provided novel insights to age-old problems of human existence from the psychoanalytic perspective.

Jung’s “Analytical psychology” refined many Freudian concepts and emerged as the first major alternative to Freudian theory (1900); however, Jung retained Freud’s terminology [Unconscious, Conscious and Preconscious], and as a result the same terms often carry different meanings. Jung (1912) renamed the Id as the Personal Unconscious, the Ego as the Personal Conscious [although the term Ego also appears in some of Jung’s writings], and the Super-Ego as the Collective Conscious [although the term Persona also appears in some of his writings]. After that Jung (1912) analytical psychology also added the Collective Unconscious to Freud’s (1900) structure of personality which is part of the Id.

Jung, like Freud, believed that the central purpose of personality is to achieve a balance between conscious and unconscious forces within the personality. However, Jung described two sources of unconscious forces. What is the personal unconscious, consisting of repressed or forgotten experiences similar to Freud’s preconscious level. The contents of the Personal Unconscious [Id] are accessible to full consciousness. Jung’s Personal Unconscious held complexes, which were groups of feelings with a defined theme than give rise to distorted behavioural responses. According to Hall and Lindzey (1970), “… a [complex] is an organised group or constellation of feelings, thoughts, perceptions, and memories which exists in the Personal Unconscious” (p.82). Unlike archetypes [which reflect the cumulative experiences of the entire human race, Homo Sapiens], Complexes reflect each individual’s unique experience. For example, a boy who repressed negative emotions about his mother could become an adult with the complex, experiencing intense feelings and anxieties when images or stimuli associated with motherhood are encountered [because they are dominated by their mothers (e.g. some mothers might offer nourishment only after – not before – their babies stop crying, thus communicating the unconscious message that the mothers are all-powerful].

The second source of unconscious forces, you need to Jung’s theory, is the Collective Unconscious, more powerful source of energy that contains inherited contents shared with other members of a particular group, i.e. it consists of aspects of personality, common to all humans, that we have inherited from our ancestors. Jung here was talking about individual similarities and not differences in personality. As the personal unconscious has complexes, the collective unconscious has archetypes, defined as primordial images evolved from human beings primitive ancestry of specific experiences and attitudes passed on over centuries [after all humans did evolve from basic primates to the sophisticated beings were now are]. Hall and Lindzey (1970) define archetype as “…a universal thought form (idea) which contains a large element of emotion” (p.84). Although modern science has shown that direct environmental influences has more power in shaping the individual mind, some aspects may be retained from evolutionary psychology although it is important to consider the fact that human societies are constantly evolving in more ways than one. At the time that Jung devised his theory however, he listed such archetypes as birth, death, unity, power, God, the devil, magic, the old sage and the earth mother. As Weitz (1976) noted, according to Jung’s Analytical Psychology, archetypes equip humans to interact with particular aspects of their physical and social worlds in a particular manner, thus archetypes are adaptive from an evolutionary standpoint. For example, Jung (1912) contended that all humans possess a “mother figure” archetype that not only gives them readily accessible image of a generic mother at birth but also predisposes them to interact with their actual mothers in a particular manner [e.g. crying, sucking]. Solomon (2003) noted that in Jung’s Theory, collectively experienced archetypes provide basic themes around which personally experienced complexes are organised. For example, all individuals are born with a readiness to seek nourishment from their mothers (the mother archetype), some individuals may find that their mothers use this readiness against them (mother complex).

The notion of a collective unconscious in personality that provides the individual with patterns of behaviour fits well with Jung’s preoccupation with myths and symbols. Jung believed that the adequacies of a society’s symbols to express archetypal images are an index of the progress of civilisation. [A good example would be the Ancient Greeks who after sophisticating their society through the evolution of their values, philosophy & educational system, saw peasants turn into conquerors, sculptors, poets and artists who even went on to colonise countries that later changed the history of those who colonised them in timeless ways / See: L’épopée de la Grèce antique (2016)].

Jung focussed on the middle years of life, when the pressures of sexual drives supposedly give way to anxiety about the more profound philosophical and religious issues of the meaning of life and death. By reinstating the notion of the spiritual soul, Jung argued that the healthy personality has realised the fullness of human potential to achieve self-unity and complete integration. According to Jung, this realisation occurs only after the person has mastered obstacles during the development of personality from infancy to middle age. Failure to grow in this sense results in the disintegration of personality. Accordingly, the person must individualise experiences to achieve a “transcendent function” by which differentiated personality structures are unified to form fully aware self.

Both Jung (1921) and Freud (1905) wrote about libido, or psychic energy, that presumably fuels individuals’ behaviour, however Jung viewed libido in a less sexualised form. Jung redefined libidinal energy as the opposition of introversion – extraversion in personality, bypassing Freud’s extreme sexual emphasis. Extraversion forces are directed externally of the people and the environment, and then nurture self-confidence. Introversion leads the person to an inner direction of contemplation, introspection and stability. Jung (1921) believed that all individuals are capable of experiencing introversion as well as extraversion over time, however, individuals at any particular point in time may be characterised as experiencing either introversion or extraversion. The opposing energies must be balanced for the proper psychological functioning sensation, thinking, feeling and intuition. An imbalance between extraversion introversion is partly compensated for in dreams. Indeed, for Jung dreams have important adaptive value in helping the person maintain equilibrium. Jung has been praised for developing a dichotomy of flow of psychic energy [i.e. introversion vs extraversion] that has been recast as one of the major personality traits in various trait theories [for empiricists who believe the main focus should be the “conflict-free” conscious part of the ego, to which many basic concepts of Cognitive Psychology can be applied].

In addition to introversion versus extraversion as a pair of opposing directions of flow of psychic energy [i.e. inwards versus outwards], Jung (1921) postulated that thinking vs feeling and sensing vs intuition represent 2 pairs of opposing modes of adaptation and functioning.

As Jung grew older, his writings increasingly came to emphasise mysticism and religious experiences, domains usually ignored by mainstream empirical psychology. Out of all the early founders of psychoanalysis, Jung held views in sharpest contrast to those of empiricism. However, he offered a unique treatment of critical human issues that had not been systematically studied by psychologists and still remain in the realm of speculative philosophy. Perhaps Jung was more of a philosopher than a psychologist, and he provoked and confronted issues not readily accommodated in other systems of psychology.

 

Jacques Lacan (1901 – 1981)

Jacques Lacan

One of the most famous post-Freudian development, especially popular in Europe and South America, was initiated by the colourful French psychoanalyst Jacques Lacan. Lacan was the son of a successful oil and soap salesman from Paris. His mother was a firm Catholic and his younger brother entered a monastery in 1929.

During the early 1920s, Lacan actively engaged with the Parisian literary and artistic avant-garde movements. Having met James Joyce, he was present at the bookshop where the first readings of passages from Ulysses in French and English took place, shortly before it was published in 1922. Lacan also had meetings with Charles Maurras, whom he admired as a literary stylist, and he occasionally attended meetings of Action Française (of which Maurras was a leading ideologue), of which he would later be critical on some aspects that he firmly disagreed and considered as outdated, such as the positivist sociology of Maurras which presents the subject as a simple product of his « milieu » [circle], derived from his culture which was even pushed to absurd extremes by Édouard Pichon to theorise about a « national unconscious ». Lacan was more avant-garde and perhaps unknowingly embraced future psychological advances of neuroscience by founding his logic on the thesis of German biologist and philosopher Von Uexküll who convincingly argued about the multitude of determining factors of the environment and not simply the basic evolution of species, but on the sophisticated elaboration of language which identifies the development of the individual psyche to a social structure.

Lacan developed psychoanalytic theory in radically new directions that relied heavily on linguistic theory and other intellectual trends in the late 20th-century France, such as the structuralist movement. It was proposed that the Unconscious is structured like a language, so that its operations can be likened to linguistic phenomena [e.g. repression was likened to a metaphor]. Hence, to uncover unconscious material the psychoanalyst must decipher a chain of clues with a great deal of verbal dexterity. Lacan also held that the ego [le Moi], although conscious and able to orchestrate a wide range of operations, is not a complete organ of self-control as ego psychologists from the US maintained, but largely also an unstable and ultimately illusory sense of personal unity. To Lacan, our sense of wholeness is a fiction and our selves are profoundly “de-centred” around a tissue of identifications with people [and characters] we have known [directly or indirectly exposed to – this extends to the arts, fictional characters, mentors, etc].

According to Lacan’s (1973/1977) version of Psychoanalytic Theory, Ego Psychologists [e.g. Anna Freud, Heinz Hartmann, Erik Erikson] and Object Relations Theorists [e.g. Melanie Klein, Donald Winnicott and Ronald Fairbairn] had strayed too far from Freud’s original (1900, 1923) original version of psychoanalytic theory. This is even in direct contrast to Jacques Lacan’s own mentor, Ego Psychologist Rudolph Loewenstein who was also a close associate and collaborator of Ego Psychologist Heinz Hartmann.

Lacan, however, seems to have set the record straight in accentuating the fundamental and widely accepted foundations of psychoanalysis by advocating a “return to Freud” [not Anna Freud’s (1923) version of Ego Psychology], but rather to Sigmund Freud’s Topographic Model of the 1900 that defined the mind into 3 levels of awareness, i.e. the Unconscious, the Preconscious and the Conscious.

Rocha (2012) noted that Lacan (1973/1977) was especially concerned with the Unconscious [l’inconscient, le « Ça », the « It », the ID] as the “ideal worker” within individuals’ personality structures. In a 1973 television interview, Lacan famously argued that the Unconscious does not “think, nor calculate, nor judge; the unconscious simply works!” Lacan contended that like the ideal worker in a capitalist society, the Unconscious generates a product in compliance with rigid, hierarchical rules and regulations – in particular, the product of unthinking and unquestioning fulfilment of individuals’ desire – which seems like something psychoanalysis should address and change for a humane, intelligent and creative civilisation.

As for dreams, Lacan argued convincingly that dreams are important products of the Unconscious [l’inconscient, le « Ça », the « It », the ID] that allow individuals to “feel” [at least during the sleeping state] that they have fulfilled their desire, however, dreams may also contain anxiety-provoking contents that individuals do not desire. As Meyer (2001) interestingly pointed out, in Lacan’s psychoanalytic theory, the problem of the Unconscious [l’inconscient, le « Ça », the « It », the ID] in finding expression is the problem of discourse with the “Other” [Le grand « Autre », the big « Other », Preconscious Superego in the domain of the symbolic]. Indeed, infants enter the world without knowing how to communicate their desire to caregivers via language, with its own rules and structure. It is also to be noted that in Lacanian Theory of Psychoanalysis, infants’ desire arises from the “loss and longing” that they experience when they are separated from their caregivers [especially their mothers] – precisely the person from whom the infants first learn early forms of communication [language]. Waintrater (2012) also pointed out that in Lacan’s Theory, individuals’ desire are not solely tied to infantile sexuality. If anything, Lacan’s concept of unconscious desire complements John Bowlby’s (1969) concept of infants’ need for attachment. Lacan uses the term « Manque« , French for « Lack » which is always related to desire. It is a lack which causes desire to arise [desire is the metonymy of the lack of being (manque-à-être)], however the precise nature of what is lacking varies. In 1955, when the term « Manque (Lack) » first appears, it designates first and foremost « manque-à-être » [want-to-be] which is the « lack of being« , hence what is desired is « being », i.e. not the lack of this or that, but the lack of « being » whereby the being exists, this lack of being [manque-à-être] is the heart of analytic experience and the very field in which the neurotic patient’s passion is deployed. An important distinction to be noted for Lacanian oriented psychoanalysts and theorists is between the lack of being [Manque-à-être / want to be] which relates to desire, and the lack of having [Manque-à-avoir] which relates to demand.

 

Distinction between Need, Demand & Desire

Need

In the context of this distinction, « need » comes close to what Freud referred to as « instinct » (Instinkt); that is, a purely biological concept opposed to the realm of the drive (Trieb), it is an appetite which emerges according to the requirements of the organism and which abates completely (even if only temporarily) when satisfied. The human subject, being born in a state of helplessness, is unable to satisfy its own needs, and hence depends on the Other [usually a role occupied by the mother in most cases] to help it satisfy them. In order to get the Other’s help, the infant must express its needs vocally; need must be articulated in demand. The primitive demands of the infant may only be inarticulate screams, but they serve to bring the Other to minister to the infant’s needs. However, the presence of the Other soon acquires an importance in itself, an importance that goes beyond the satisfaction of need, since this presence symbolizes the Other’s love. Hence demand soon takes on a double function, serving both as an articulation of need and as a demand for love. However, whereas the Other can provide the objects which the subject requires to satisfy his needs, the Other [usually mother at this stage] cannot provide that unconditional love which the subject craves. Hence even after the needs which were articulated in demand have been satisfied, the other aspect of demand, the craving for love, remains unsatisfied, and this leftover is desire.

The concept of a pre-linguistic need is thus merely a hypothesis, and the subject of this pure need is a mythical subject; even the paradigmatic need of hunger never exists as a pure biological given, but is marked by the structure of desire. Nevertheless, this hypothesis is useful to Lacan for maintaining his theses about the radical divergence between human desire and all natural or biological categories. Need is thus an intermittent tension which arises for purely organic reasons and which is discharged entirely by the specific action corresponding to the particular need in question.

 

Demand

Lacan argues that since the infant is incapable of performing the specific actions that would satisfy its biological needs, and hence Lacan bases the distinction on the fact that in order to satisfy his needs the infant must articulate them in language; in other words, the infant must articulate his needs in a « demand » [for them to be met by the mother who will perform the specific actions]. However, in doing so, something else is introduced which causes a split between need and demand; this is the fact that every demand is not only an articulation of need but also an (unconditional) demand for love. Now, although the Other to whom the demand is addressed (in the first instance, the mother) can and may supply the object which satisfies the infant’s need [e.g. the breast to satisfy the child’s hunger], she is never in a position to answer the demand for love unconditionally, because she too is divided. The result of this split between need and demand is an insatiable leftover, which is desire itself. It is this double function which gives birth to desire, since while the needs which demand articulates may be satisfied, the craving for love is unconditional and insatiable, and hence persists as a leftover even after the needs have been satisfied; this leftover constitutes desire. In the seminar of 1956-7, Lacan argues that the cry of the human infant — its call (l’appel) to the mother — is not merely an instinctual signal but is « inserted in a synchronic world of cries organized in a symbolic system. » In other words, the infant’s screams become organized in a linguistic structure long before the child is capable of articulating recognisable words.

Demand is thus intimately linked to the human subject’s initial helplessness. By forcing the patient to express himself entirely in speech, the psychoanalytic situation puts him back in the position of the helpless infant, thus encouraging regression.

« Through the mediation of the demand, the whole past opens up right to early infancy. The subject has never done anything other than demand, he could not have survived otherwise, an we just follow on from there. » However, while the speech of the patient is itself already a demand (for a reply), this demand is underpinned by deeper demands (to be cured, to be revealed to himself). The question of how the psychoanalyst engages with these demands is crucial. Certainly the psychoanalyst does not attempt to gratify all of the patient’s demands, but nor is it simply a question of frustrating them.

 

Desire 

Lacan follows Spinoza in arguing that « desire is the essence of man. » Desire is simultaneously the heart of human existence and the central concern of psychoanalysis. However, when Lacan talks about desire, it is not any kind of desire he is referring to, but always « unconscious » desire. This is not because Lacan sees conscious desire as unimportant, but simply because it is unconscious desire that forms the central concern of psychoanalysis. The aim of psychoanalytic treatment is to lead the patient to recognise the truth about his/her desire. It is only possible to recognize one’s desire when it is articulated in speech. Hence in psychoanalysis, « what’s important is to teach the subject to name, to articulate, to bring this desire into existence. « However, it is not a question of seeking a new means of expression for a given desire, for this would imply a expressionist theory of language. On the contrary, by articulating desire in speech, the patient brings it into existence.

« That the subject should come to recognise and to name his desire; that is the efficacious action of analysis. But it isn’t a question of recognising something which would be entirely given. … In naming it, the subject creates, brings forth, a new presence in the world. » [adds to reality what was previously not there through language].

However, there is a limit to how far desire can be articulated in speech because of a fundamental « incompatibility between desire and speech; « it is this incompatibility which explains the irreducibility of the unconscious (i.e. the fact the the unconscious is not that which is not known, but that which cannot be known). « Although the truth about desire is present to some degree in all speech, speech can never articulate the whole truth about desire; whenever speech attempts to articulate desire, there is always a leftover, a surplus, which exceeds speech. » It is important to distinguish between desire and the drives. Although they both belong to the field of the Big Other (as opposed to love), desire is one whereas the drives are many. In other words, the drives are the particular (partial) manifestations of a single force called desire (although there may also be desires which are not manifested in the drives). There is only one object of desire, object (petit) a, and this is represented by a variety of partial objects in different partial drives. The object (petit) a is not the object towards which desire tends, but the cause of desire. Desire is not a relation to an object, but a relation to a lack (Manque-à-être / Lack of being). One of Lacan’s most often repeated formulas is: « man’s desire is the desire of the Other [Big Othe/Superego]. » This can be understood in many complementary ways, of which the following are the most important:

Desire is essentially « desire of the Other’s desire », which means both desire to be the object of another’s desire, and desire for recognition by another. Desire is essentially a desire for recognition from this ‘Other’; secondly desire is for the thing that we suppose the Other desires, which is to say, the thing that the Other lacks.

Lacan takes this idea from Hegel, to state:

Desire is human only if the one desires, not the body, but the Desire of the Other [Big Other / Superego] . . . that is to say, if he/she wants to be ‘desired’ or ‘loved’, or, rather, ‘recognised’ in his/her human value. . . . In other words, all human, anthropogenetic Desire . . . is, finally, a function of the desire for ‘recognition‘.

Thus, desire is a constant force which can never be fully satisfied [because humans tend to have other desires once one is achieved], the constant ‘pressure’ which underlies the drives and keeps us moving forward.

 

Mirror Stage: the birth of the Ego [Le Moi]

Malin (2011) pointed out that in Lacanian Theory, a major event in infants’ personality and social development is the mirror stage, when infants enter into language as a uniquely human form of interaction with all caregivers in the child’s environment [although infants are not likely to consciously experience language prior to age 2]. As Luepnitz (2009) noted, Lacan believed that infants often enter into language at a crucial point when they literally recognise themselves in a mirror, with caregivers [i.e. can include others such as teachers rather than direct parents] pointing to the reflection and approvingly saying to the infants, “Look, that’s you!” – even if infants are unlikely to remember the event in itself.

Rene Magritte - Not To Be Reproduced (1937)

« Not to be reproduced » by René Magritte, 1937

And as Hivernel (2013) noted, the 2 major outcomes of the mirror stage are the emergence of the Subject, a product of the symbolic field (i.e., individuals’ gradual awareness regarding their uniqueness) and the Other (i.e. individuals’ gradual awareness regarding the rest of humanity, to whom they are connected to varying degrees). A further major outcome of the mirror stage is the birth of the Ego [Le Moi, an imaginary formation], and infants may experience joy at this moment, which occurs (and, in fact, is necessary) before infants can truly understand the power of symbols in language. However, as already mentioned, one of the unfortunate outcomes of the mirror stage was that infants gradually begin to look outward, and not inward in search for identity; and such external orientation toward individuals’ own identity is doomed to fail. This seems to make perfect sense even from the objective and mechanistic outlook that the Organic Theory considers; i.e., any organism whose reality or sense of it is based on the geographical mental conditioning of a group of organisms [about 4 or 5] will have a limited perspective of reality and lack a wider outlook of the world as it truly is.

 

The Power of Language

Gillett (2001) noted that, in Lacan’s view, language does not perfectly convey individuals’ desire to other persons, partly because individuals do not fully understand their own desire, and partly because language is an inherently social medium that can lead to misunderstanding as well as understanding between individuals and other persons. Language however is a very powerful social medium [as can be seen also from the essay, The Concept of Self]

Le Langage et la Réalité dpurb 1200

Traduction(EN): « There has always been something special about language because language creates reality. Language reveals the truth of the subject and adds to reality what was not there before. Hence, the difference between truth and reality is that truth adds to reality what was not there before. Empiricists who study traits should remember that constructs would not exist if they had not first been created through language. Hence language, creates reality! » -Danny J. D’Purb

Lacan proposed that the unconscious is structured like language. In the unconscious as well as in the acquisition of language, individuals may follow rules regarding the use of symbols without having deliberately learned [and without having overtly been taught] those rules [something “special” and even “mystical” about language]. In addition the unconscious [like language] is regarded as a “network of signifiers” with the term signifier (le significant) referring to any symbol that is used [on its own, or in combination with other symbols] to stand in for, or to represent, something else [the signified – le signifié].

 

The 3 Registers: Symbolic, Imaginary & Real

The Symbolic [which is constructed largely via language] is one of the aspects of the Subject that is revealed via individuals’ dreams, and it is the cornerstone of Lacanian theory because the Subject’s relationship with the Symbolic is the heart of psychoanalysispsychoanalysts are essentially practitioners of the symbolic function [culture and symbolic are thus imposed on nature]. Lacan criticises the psychoanalysis of his day for ignoring the symbolic domain and reducing everything to the imaginary and this for Lacan is a betrayal of Freud’s most basic insights; « Freud’s discovery is that of the field of effects, in the nature of man, produced by his relationship to the symbolic order« . Lacan argues that it is only by working in the symbolic field that the psychoanalyst can produce changes in the subjective position of the patient and foster progress and growth; these changes will also produce imaginary effects [on the Ego « Moi »] since the imaginary is structured by the symbolic. Hence, it seems to suggest that a healthy Ego [Le Moi] will produce appropriate imaginary effects and contribute to the individual’s desires and unique personality since it allows the Subject to imagine creatively while regulating the desires of the Unconscious [ID / It / Ça / Inconscient] according to the symbolic laws of the Big Other [Grand Autre / Superego with the ID], and the balance between these 3 domains [ID – Superego – Ego] differs from one individual to the other leading to differences in personality.

Other structural components [or registers] of the Subject that are revealed via dreams are the Imaginary and the Real [Real simply stands for what is neither symbolic or imaginary and is never truly known – it is mediated by the 2 orders of the Imaginary and the Symbolic, thus while it is present, these uncanny objects are treated as alien and reminders of symbolic lack in the subjects identity formation]. The Imaginary order is based on the formation of the Ego in the mirror stage by identification with the counterpart [or specular image] and this dual relationship between the ego and the counterpart is characterised by narcissism and alienation. Lacan also accused the major psychoanalytic schools of reducing psychoanalysis to the imaginary order since it is the dimension of the human subject which is most closely linked to animal psychology, but yet it is structured by the symbolic and this means that in man the imaginary relation has deviated from the realm of nature and is in fact the realm of image and imagination, deception and lure. The principal illusions of the imaginary are those of wholeness, synthesis, autonomy, duality and similarity.

Lacan argued that the psychanalyst’s interpretation of dreams can be viewed as analogous to a linguist’s translation of a language, unearthing the meaning that particular symbols hold for an individual [e.g. a client in psychotherapy]. Lacan noted that a specific difficulty that arises when psychoanalysts interpret the content of clients’ dreams is that, by the time the clients have awakened a large portion [if not most or all] of the dream has vanished, and this can be problematic if clients are reflecting on dreams that they experienced several year (decades?) ago. According to Lacanian Theory, Marder (2013) noted that dreams are oriented towards future interpretation, by dreamers themselves or by someone else (e.g. Psychoanalysts). Hence, truly important content are likely to survive clients’ transition from sleeping to waking states.

Lacan also pointed out as Stockholder (1998) noted, that Freud’s (1923) Structural model, i.e. the later version of his Psychoanalytic Theory with its dictinctions among Id, Super-Ego and Ego had distorded the true meaning of the first Topographic Model. And perhaps rightly observed, since the Ego which was meant to be conscious, revealed an unconscious element in its ability to instantly generate defence mechanisms outside the awareness of the patient, when before the function of the Ego was just one component present in the Conscious, i.e. the Ego [le Moi], was a part of the « Conscious », as a level of consciousness and not assumed to be a distinct mental functions as part of the new 3 part dissection [ID, SuperEgo and Ego]. However, they can be synthesised and enhanced, as we are doing with Freud, Jung and Lacan along with other discoveries in the realms of Neuroscience and Cognitive-Psychology to explore the psychology of the singular organism and its powers of definition to a level that no other psychologist has attempted to before our endeavour.

Lacan’s theory relocates the ID [Ça / L’Inconscient / Symbollic], Super-Ego [Surmoi, Le grand Autre: the big Other / Symbolic] and the Ego [Moi / Imaginary order] across the Unconscious, Preconscious and Conscious.

 

The Subject: Uniqueness in the speaking being, le parlêtre

Although psychoanalytic treatment has powerful effects on the ego, it is the Subject, and not the ego, on which psychoanalysis primarily operates. Different from the ego, the Subject is a product of the symbolic Grand Autre, i.e. the « Big Other » [Superego under the influence of the ID]. The Subject means no more than « human being » and in 1953 Lacan establishes a clear distinction between the Subject and the Ego which remained a one of the most fundamental distinctions in his work.  Whereas the Ego is part of the imaginary order, the Subject is parf of the symbolic. Lacan distinguished between 3 kinds of subject. Firstly, we have the impersonal subject, independent of the other, the pure grammatical subject, the noetic subject, the « it » of « it is known that ». Secondly, we have the anonymous reciprocal subject who recognises himself in equivalence with the other (ego reflection / petit autre / little other). Thirdly and finally, we have the personal subject in his uniqueness completely constituted by the act of self-affirmation. It is the third sense of the term subject, i.e. the personal subject in his uniqueness that constitutes the focus of Lacan’s work, and this also seems to be in line with our philosophy of construction and singularity in the creation of the individual. Lacan’s subject is the « subject of the unconscious », i.e. it is a product of the expression of the unconscious through the symbolic « Grand Autre » [Superego]. Lacan argues that this distinction can be traced back to Freud: « [Freud] wrote Das Ich und das Es in order to maintain this fundamental distinction between the true Subject of the unconscious and the Ego as constituted in its nucleus by a series of alienating identifications. A complex and unique domain such as the subject should not be objectified or reduced to a thing; « What do we call a subject? Quite precisely, what in the development of objectivation, is outside of the object. » References to language come to dominate Lacan’s concept of the subject from the mid-1950s on. He distinguishes the subject of the statement from the subject of the enunciation to show that because the subject is essentially a speaking being (parlêtre), he is inescapably divided. In the early 1960s Lacan defines the subject as that which is represented by a signifier for another signifier; in other words, the subject is an effect of language and in philosophical discourse, it denotes an individual self-consciousness. This perfectly illustrates Lacan’s thesis about the determination of consciousness by the symbolic register. « The subject is a subject only by virtue of his subjection to the field of the Other [Grand Autre / Big Other / Superego / from the Symbolic resgister]. » The philosophical connotations of the term « Subject » are particularly emphasised by Lacan, who links it with Descartes’s philosophy of the cogito [« Je pense donc que je suis »]: « in the term subject . . . I am not designating the living substratum needed by this phenomenon of the subject, nor any sort of substance, nor any being possessing knowledge in his pathos . . . nor even some incarnated logos, but the Cartesian subject, who appears at the moment when doubt is recognised as certainty. » The fact that the symbol of the subject, S, is a homophone of the Freud’s term Es (‘Id’) illustrates that for Lacan, the true subject is the subject of the unconscious [i.e. the impact of the expression of the instincts and language of the unconscious through the SuperEgo/Big Other/Grand Autre on the subject and ego – which differs in individuals. Lacan forced us to admit that we all have mental automatism. We all have, deep inside us, this inner voice that will inhabit the language [or languages] with which we will speak. Perhaps a good example of the expression of the unconscious inner voice is through music, which Lacan saw as a fundamental language of our unconscious thoughts, and therefore the bearer of an enigmatic knowledge, i.e. a form of language that would therefore have a meaning, corresponding for example to that of the different emotions that satisfy the various states of mind and that possibly supports an imaginary form of communication]. In 1957 Lacan strikes through this symbol to produce the symbol $, the « barred subject, » thus illustrating the fact that the subject is essentially divided.

Niklos Koda Tome 7 Magie Blanche et Le spiborg - Mort et Déterré

Déssins: « Niklos Koda » par Olivier Grenson & « Mort et Déterré » par Jocelyn Boisvert et Pascal Colpron

 

Super Ego (Big Other / Grand Autre): an early form of conscience in the symbolic register, the mysterious origins of speech & the social bond of language

Lacan distinguishes between the Superego and the ego-ideal [terms that Freud used interchangeably in the Ego and the Id] and argues that the primary function of the Superego is to repress sexual desire for the mother in the resolution of the child’s early Oedipus complex and following Freud he also argues that the Superego is an early form of conscience that develops from the Oedipal identification with the father but also incorporates the maternal origins of an archaic form of the superego [conscience] derived from Melanie Klein’s thesis. Hence, the Oedipus complex is a process which imposes Symbolic structures on sexuality and allows the Subject to emerge. When Lacan returned to the subject of the Superego [Grand Autre / Big Other] in his 1953-4 seminar, he located it in the symbolic order, as opposed to the imaginary order of the ego: the superego is essentially located within the symbolic plane of speech and has a close relationship with the « law » [law here does not refer to a particular piece of legislation, but to the fundamental principles which underlie social relations, i.e. a set of universal principles which makes social existence possible, the structures that govern social exchange, for e.g. gift giving or the formaton of pacts. Since the most basic form of exchange is communication [e.g. the exchange of words, the gift of speech], the symbolic « law » is fundamentally a linguistic entity/dimension, it is the law of the signifier. This law then is revealed with an order of language – the symbolic order itself. Lacan argues that the « law » is human because it separates man from other animals by regulating sexual relations that are among animals, unregulated. It is the law of the pleasure principle which commands the subject to « Enjoy as little as possible » and this maintains the subject at a safe distance from the « Thing » (the forbidden object of desire, known as the « objet petit a » which is any object which sets desire in motion and is the object of anxiety), making the subject circle round it without ever attaining it because if the subject transgresses, it is experienced as suffering/evil – it is fortunate then that the thing (which is not an imaginary object but firmly in the register of the real) is usually inaccessible and/or out of direct reach]. The « law » as such is a symbolic structure which regulates subjectivity and in this sense prevents disintegration of the wholeness of the individual’s psycheThe law of the superego however is believed to have a senseless and blind character of pure imperativeness and simple tyranny, so it is at one and the same time the law and its destruction, the Superego [only partially conscious] is thus the « big Other » which imposes a purely oppressive morality on the neurotic subject but also the will-to-enjoy and is related to the voice. The big « Other » must be considered a locus in which speech is constituted, it is thus only possible to speak of the « big Other » as a subject in a secondary sense where a psychoanalyst may occupy this position and thereby « embody » the « Big Other » for a patient.

In arguing that speech originates not in the Ego or even in the Subject, but in the partially unconscious « big Other » [Superego], Lacan is stressing that speech and language are beyond conscious control, they come from an other place, outside consciousness, and hence « the unconscious is the discourse of the big Other » [the effect on the subject of speech that is addressed to that subject from elsewhere, by another subject (forgotten or unknown) from another scene or psychic locality] and belongs wholly to the symbolic order. In 1969, Lacan begins to use the term « discourse » to denote a « social bond » founded in language; an incredibly rational observation because there is nothing more social that language – the vital ingredient in any form of social activity.

Parlez-vous Lacan

In conceiving the « big Other » as a place, Lacan alludes to Freud’s concept of not physical locality, but « psychical locality« , in which the unconscious is described as « the other scene ». It is highly likely that the impact of the arts, education, exposure and personal development has an important role to play in the development of the partially unconscious « big Others ». The big Other is always « lacking » something for the subject and the mythical complete and perfect Other does not seem to exist. In 1957, when Lacan introduces the algebraic symbol for the barred Other (A), lack comes to designate the lack of a signifier in the Other. Lacan introduces the symbol S(A) to designate « the signifier of a lack in the Other. [Note that Lacan uses the term « Grand Autre » with capital A which here is referred to as the « Other » with capital O, i.e. the « big Other » and not the « petit autre » which is the reflection or projection of the Ego [counterpart and specular image] in the imaginary order referred to as the « other » or « little other », « o » « petit autre » « a ».]

 

Lacanian Terms: Inconscient, Grand Autre & Moi

To clarify Lacanian terms, we have the « inconscient« ; being the unconscious ID in the domain of the symbolic which is the unconscious origin of speech, the symbolic « it » or « Ça » beyond the imaginary ego: man is lived and spoken by the unconscious « it » or « Ça ». Hence the phrase which Lacan frequently uses when discussing the unconscious ID, « it speaks » (le « Ça » parle). Hence, Lacan argued that the concept of the unconscious was badly misunderstood by most of Freud’s followers who reduced it to being « merely the seat of instincts« , and against this biologistic mode of thought Lacan argued that the unconscious is not simply the seat of instincts but is also and primarily linguistic because we can only grasp the unconscious when it is explained and transformed into words. One should see in the unconscious the effects of speech on the subject, as it is the determination of the subject by the symbolic order. The unconscious is a kind of memory in the sense of a symbolic history of signifiers that have determined the subject in the course of his life. What this seems to suggest is that the unconscious absorbs a wide range of signifiers (signifiants) [that symbolise something else, « le signifié » or « signified » in a deeper exploratory sense] throughout the subject’s life and these later find expression and guide desires through the Superego [Grand Autre / Big Other / the symbolic discourse of the unconscious] and in turn symbolically shapes the imaginary creations of the Ego [Moi] and define the Subject according to his abilities to achieve his desires – the outcome differs depending on the subject’s individual creativity and intelligence.

Le Penseur par Auguste Rodin (1882) dpurb site

«Le Penseur» par Auguste Rodin (1882) représente un homme dans une réflexion profonde, semblant utiliser toute son intelligence pour résoudre un problème.

For the Cognitive-Behavioural mind, these signifiers may be considered as « stimuli » [received in different forms, e.g. visual, auditory, mental] however their reception and their responses are completely unconscious and generate effects in the depth of the mind [unconscious] that cannot be measured or seen.

We then have the « Autre » or « Grand Autre » or « Big Other » which is the preconscious Superego also in the domain of the symbolic; being the discourse of the unconscious. The big « Other » designates an otherness that transcends the illusory otherness of the imaginary because it cannot be assimilated into the psyche through identification, Lacan equates the big « Other » with language and the « law » [the structures that govern social exchange] and hence the big « Other » is inscribed in the symbolic order, and indeed the big « Other » is symbolic because it differs for each subject and is the symbolic order which mediates the relationship with a particular subject. The little « other«  is a reflection or projection of the ego, it is the counterpart and the specular image, unlike the « big Other » which is in the symbolic order, the little « other » is inscribed in the imaginary order of the Ego.

Finally we have the « moi », which is the equivalent of the Ego, a formation in the domain of the imaginary as opposed to the subject, which is a product of the symbolic order.  The Ego is a méconnaissance of the symbolic order, the seat of resistance and is structured like a symptom at the heart of the subject, the human symptom par excellence, the mental illness of man. Lacan also argued that the proponents of ego-psychology betrayed Freud’s radical discovery by relocating the ego as the center of the subject. In opposition to this school of thought, Lacan maintains that the ego is not at the center, that the ego is in fact an object. ‘ The ego is a construction which is formed by identification with the specular image in the Mirror stage and is thus the place where the subject becomes alienated from himself, transforming himself into the counterpart. Unlike US Ego psychologists who considered the Ego as the dominant component that should be worked on and strengthened, Lacan argued against such irrational therapy because the ego is the « seat of illusions » and to increase its strength would only increase the subject’s alienation, the ego is the source of resistance to psychoanalytic treatment and strengthening it would increase those resistances. Lacan argued that the true goal of psychotherapy should be therapists’ unearthing the clients’ unconscious desire via the “talking cure” of psychoanalysis – not strengthening the Ego [mindlessly, as this may leave individuals in a state of delusion without an ego adjusted to their abilities – and may even lead to individuals allowing their Ego [imaginary moi] to dominate the Super-Ego [Grand Autre, Big Other] and favour irrational release of the ID’s [Inconscient / Ça] psychic energy without any remorse or rational control]. Because of the imaginary fixity of the ego, it is resistant to all subjective growth and change and to the dialectical movement of desire, hence, by undermining the fixity of the ego, psychoanalytic treatment aims to restore the dialectic of desire and reinitiate the « coming into being » of the subject. This is in direct contrast to the Ego Psychologists’ perspective.

 

The concept of Adaptation and Psychoanalysts as the Grand Autre [Big Other / Superego]

Lacan also questioned whether the ego of the psychoanalyst gives the measure of reality to the patient in trying to adapt the latter. Because if so, this would turn the analyst [who are also different in terms of talent, creativity and vision from one person to another] into the arbitrer of the patient’s adaptation to reality, hence the analyst’s own understanding [or lack of understanding] of reality would be assumed to be absolute and perfect where he would be considered as the perfection of adaptation compared to the patient [as is the case in Ego-psychology practiced in the USA]. This to Lacan turns psychoanalysis as an exercise of power and social control where the analyst forces his own particular view of reality onto the patient and this is not psychoanalysis but suggestion. This Lacanian refusal to force an adaptation of the ego to reality is in direct opposition to the « Ego-psychology » of the US psychoanalytic movement that Lacan accused of wrongly reading the works of Freud. Lacan regards it as simple to understand why the adaptation theme was developed by European and Jewish psychoanalysts who had emigrated to the USA in the late 1930s, and this is simply because these analysts felt not only that they had to adapt to life in the USA, but also that they had to adapt psychoanalysis to American tastes [i.e. to fit the average american psyche].

The simplistic biological concept of adaptation [as often assumed in simple deterministic animal psychology] can be problematic when applied to psychoanalysis since in biology it is assumed that organisms/animals are driven to adapt themselves to fit the environment and hence implies a harmonious relation between the Innenwelt (inner world) and Umwelt (surrounding world), but in psychology this can be worsening problems of society and human existence when the Umwelt (surrounding world) itself which is assumed to be « reality » is not a simple objective thing but is itself a product of the ego’s fictional misrepresentations and projections. So, the idea of harmony between the organism and its environment which is implicit in the concept of adaptation from the simplistic biological perspective is innaplicable to human beings since man’s inscription in the symbolic order re-shapes and restrains his natural behaviours [i.e. because of civilised society and the sophiscated and multi-layered aspects of human life, man cannot allow himself to follow his natural instincts blindly as animals do in nature], and this means that « in man the imaginary relation [to nature] has deviated«  [nurture vs nature debate]. This is different for all animal machines who tend to be strictly riveted to the conditions of the external environment, whereas in the human being we have « a certain biological gap ». Therefore to Lacan it is not a question of adapting to reality, but of showing the « Ego » that it is only too well adapted since it assists in the construction of that very reality and hence the task of the psychoanalyst is rather to subvert the patient’s illusory sense of adaptation since it blocks access to the unconscious, and hence gain access to itIn 1955 Lacan states that « the dimension discovered by analysis is the opposite of anything which progresses through adaptation » and hence refused to explain human phenomena and mental life in terms of adaptation. To Lacan, and many inspired by his views, it is more about « adjusting » than adapting, i.e. adjusting to be functional in our chosen path/field.

Lacan maintained that psychoanalytic intervention should not aim to adapt the Ego to reality, and this seems reasonable since « reality » is a social construct under constant change as we primates are evolving and adapting to the discoveries of our constantly changing civilisation. But also because the ego is an imaginary formation as opposed to the subject which is the true product of the symbolic. To Lacan, psychoanalysts should adopt the role of the big « Other » in therapeutic interventions as a counterpart to the clients’ Subject, thus making it possible for clients to peer beneath their own conscious (typically not completely true) narratives, into their unconscious (and “true”) desire(s) [and perhaps guide or help the patient to realise their dreams within the realms of reality within civilised society].

Lacan’s suggestion seems to give the individual the creative freedom to create himself through language and discourse, exist and be unique within the reasonable limits of a mentally adequate and healthy person, while only adjusting his behaviour to be able to function and exist in his chosen individual world without losing his individuality. Since reality and culture are social constructs that are always changing through collaboration, the individual can both be shaped by them and also shape them [for e.g. human culture teaches a child how to use a fork and a knife to eat, but it can also be shaped by an individual if he invents/discovers something or adopts a philosophy that affects/inspires human cultures. In the past smoking was allowed everywhere and it was common culture to see people and even doctors smoking in public buildings, but since we found about the harmful effects of cigarette smoke, today culture has been reshaped and smoking is banned indoor in most public places. The invention of the mobile phone has also affected human culture and behaviour when before people used public phone boxes]; this concept of being shaped by and also shaping human cultures is known as mutual constitution and is reflected in the artefacts of all societies through the arts, literature and languages [as we explained in the Essay: The Concept of Self].

Lacan was also innovative and challenged the established procedures of Psychoanalytic practice [which promoted multiple sessions lasting an hour or more apiece, across several years] to advocate brief, impromptu [i.e. unscheduled] therapy that could be completed in a matter of minutes. This seems logical since the main factors that influence successful therapy are the relationship between the therapist and the client, but also the aptitudes of the client [which varies from one individual to another depending on their reflective abilities, intelligence and will power]. Since Lacan’s theory is mainly based on French society – one with a history of challenging the limits of the individual in the name of excellence – it seems fair to acknowledge his opinions [in a sense that not all patients require multiple sessions depending on their individual characteristics and response to the relationship with the psychoanalyst and their understanding of their own mental condition and desires] as rational, economical, time-saving and flexible to accommodate individual differences.

Nous En France - Sarkozy - d'purb

Traduction(EN): « Us in France, we are different from others. To live, we have to drink, eat, but also to cultivate ourselves. » -Nicolas Sarkozy

However, partly as a reaction to Jacques Lacan’s criticism of Ego Psychoogy [as practiced in the United States], and partly as his advocacy of brief, impromptu therapy, the US-oriented International Psychoanalytic Association barred Lacan from training future psychoanalysts. Despite [or perhaps because of?] the IPA’s decision to bar Lacan from training future psychoanalysts, the proportion of Psychoanalysts adopting a Lacanian perspective has only grown since Lacan’s death in 1981with half or more of the world’s psychoanalysts adopting some Lacanian concepts. Jardim, Costa Pereira and de Souza Palma (2011) applied Lacanian Theory to understanding the personality disorder of Schizophrenia [formerly known as “madness”], interpreting a case study [along with fictional examples from literary works] in terms of failure to achieve an integrated Ego from infancy onwards. Furthermore, McSherry (2013) argued that Lacan’s Theory of Psychoanalysis could benefit mental health nursing practice since various forms of personality disorders [including but not limited to Schizophrenia] can be understood readily in terms of Lacan’s theory.

Malone (2012) noted that Lacan was ambivalent towards the growing tendency for empirical clinical psychologists to align their discipline with the hard sciences [e.g. Biology, Medecine, Physics, Chemistry, etc] and not with the humanities [e.g. Literature, Poetry, Theatre, Drama, Art, etc], and viewed psychoanalysis as ideally informed by both the humanities and by the sciences.

Documentaire: Jacques Lacan, La Psychanalyse Réinventée (2001)

Lacan has been hailed as the “French Freud” who has established a tradition of French psychoanalysis that rivals American and British psychoanalysis in terms of international influence. Although Lacan’s theory has been cast as a uniquely French theory [culturally and linguistically speaking], it has nonetheless struck a chord with many [and, perhaps, most] of the world’s influential modern day psychoanalysts, shattering perceptions across languages and cultures worldwide. Perhaps unsurprisingly, a decade later, much psychoanalytic research in the US itself will seem to confirm Lacan’s perspectives as discussed above.

LesFrancaisNapproventPasLaPolitiquedesUSA

A majority of 80% of French citizens are wary of the US and do not approve its politics / Source: Le Figaro

 

Conclusion: Legacy, Impact & Evolution

Psychoanalysis is a unique movement in psychology that grew out of the same German model of mental activity that produced act psychology and the Gestalt movement. However, psychoanalysis received its immediate expression through the needs of the mentally ill. It was born as a clinical discipline, not an academic development based on empirical methodology to fit a particular field’s reductionist requirements for acknowledgement. For this reason, psychoanalysis, especially as proposed by writers after Freud, gives the impression of an ad hoc movement that develops as particular problems arise – it could be seen as adaptive and constantly evolving. Psychoanalysis did not adhere to the commitment to methodology expressed in those mechanical systems generated by academic research. Hence, there was and still is little interaction between psychoanalysis and those systems grounded on empiricism and reductionist methodologies that are stubborn in trying to capture an entity as the mind when most of the constructs cannot be seen or touched, or accurately measured. Stated quite simply, psychoanalysis and the other schools of psychological models do not speak the same language.

Although different and hardly understood, let alone accepted by common mainstream empirical and academic psychology, psychoanalysis did assume a dominant role in psychiatry. This is completely understandable in light of the origins of psychoanalysis as a response to clinical problems as they manifested themselves. Indeed, psychoanalytic writings enjoyed an almost exclusive position in psychiatry and clinical psychology until the 1960s, when behaviour modification and Pavlovian derivatives based on Behaviourism [such as Cognitive Psychology] began to compete as an alternate model of therapy [Read: the Essay on the Origins of the Cognitive Behavioural Model: Biological Constraints in Learning, which also suggests an unconscious drift in other animals].

Pavlov Dog Labs

Psychoanalysis continues to exert a marked influence on art, literature, and philosophy. This influence reflects major contributions of Freud: his comprehensive analysis of the unconscious. On the same line, literary and artistic expressions are interpreted in light of the unconscious activities of the artist as well as the unconscious impressions of the perceiver. Psychologists today may choose unconscious motivations or simply to refer to subliminal or subthreshold activities. However, any truly comprehensive theory of psychological activity can no longer be limited to conscious aspects of behaviour. Although some psychologists may disagree with some Freudian concepts and interpretations, Freud did identity some dynamic processes that influence the activity of the individual: processes that psychology cannot ignore anymore.

As mentioned earlier, psychoanalysis has a unique position in the history of psychology. Freud did not develop a theory that generated testable hypotheses or other empirical implications. Yet, on another level, Freud accomplished what few other theorists have: He revolutionised attitudes and created a new set for thinking about personality. The findings of other more empiricist theories of personality disturbance have often confirmed many of Freud’s observations. If his views do not meet the criteria of empiricistic study, they nevertheless mark a man of genius and insight, whose influence pervades people’s thinking about themselves in ways that few others have achieved.

The psychoanalytic theory is an enormously complex and ambitious one, and it aims to make sense of a much broader array of psychological and social phenomena than other theories, and does so with a collection of explanatory concepts. Hence, the sheer range and scope of psychoanalytic theory, and its aspiration to be a total account of mental life, should be recognised and applauded. In comparison, all other schools of psychology to study personality look decidedly timid and limited in focus. Even if other approaches tend to have more empirical foundations and hence more credential in academic psychology, they tend to leave out much of what we might want to include in a comprehensive theory of human behaviour. To many intellectuals and lay people alike, any account of personality that does not acknowledge that humans are like psychoanalytic theory portrays us, i.e., driven by deeply rooted motives, inhabiting bodies that bring us pleasure and shame, shaped by our early development, troubled by personal conflicts, and often a mystery to ourselves – is fundamentally limited.

While the empirical limitations are a fact, some of these problems are due in part to the intrinsic difficulty of what psychoanalytic theory tries to explain. Others could be partially overcome if researchers made a more concerted effort to determine which psychodynamic ideas stand up to closer, “scientific enquiry”. However, psychoanalysis cannot be judged only by empirical perspectives, and it would be a mistake to abandon it impatiently, given how much a suitably revised and empirically updated theory of psychodynamics in the future might deepen the studies of personality.

Even for all its failings to the empirical scientist, on some aspects, psychoanalysis is at least partly responsible for several important and scientifically respectable ideas that has always had a kernel of truth and was later developed by other researchers. While Freud’s idea of the dynamic unconscious remains controversial, it can no longer be disputed today that unconscious cognition is now a fact and an uncontroversial idea in cognitive and social psychology, where huge volumes of research now explore non-conscious or “implicit” attitudes.

*****

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Essay // Clinical Psychology: Learning Disabilities, Anxiety, Depression & Schizophrenia and the Effectiveness of Psychotherapy

Part 1 of 5 | Children and Adolescents’ Mental Health Services (CAMHS) & Learning and Intellectual Disabilities

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CAMHS deal with the psychological issues of people under the age of 18. They are a non-specialist service and often refer to other more specialised departments following the initial assessment of patients. The most common cases tend to be adolescents with depression and anxiety whose manifestations are not different to those of adults and so are treated fairly similarly.

Inclusivism in Learning Disabilities

In 1969, Bengt Nirje adopted and developed the concept of normalisation in Sweden and beautifully described it as…

“making available to all mentally retarded people patterns of life and conditions of everyday living which are as close as possible to the regular circumstances and ways of life of society.”

– Nirje, 1980

Learning Disability is not just an impairment in Cognition

The social impairment of Learning Disabilities – US Statute 111 – 256: Rosa’s Law defines the factual impairment, the imposed or acquired disability and the awareness of being different.

The Normalisation Theory

This theory focuses on the mainstream trends of social devaluation or deviancy making. Some categories of people tend to be valued negatively due to their behaviours, appearances and characteristics, and this places them at the risk of being devalued [according to the Normalisation Theory of Nirje on the societal processes he assumed] – people fulfil various social roles and stereotypes.

learning disabilities co ltd ii

As part of the deviancy making or social devaluation, the unsophisticated minds of the masses generally do not mean to stereotype, however they seem to do it unconsciously [the unconscious is a concept Sigmund Freud and Jacques Lacan acknowledged in their psychoanalytic theories of mental/psychological activity and mental health problems linked to psychopathic tendencies in people towards others], i.e. deviant groups with social symbols or images that are at a higher risk of being devalued are the focus of the normalisation theory, which is believed to be done with the aim of providing them with the skills they need and eventually change the status of these deviant groups to functional members of society.

Lutte contre l’illettrisme En 6ème, je ne savais pas écrire mon nom ! (2016)

Society tends to distance itself from deviant groups without any purpose or belonging, however psychologists provide support for the social integration and valued social participation of people with learning disabilities through exercises that involve learning through imitation. This challenges stereotypes within wider society through direct experiences of spending time with people who are affected by learning disabilities.

While psychology evolves and sophisticated and modern theories about intelligence and communication such as our « Organic Theory » take shape, we hope that observations such as this one may be digested and understood by the masses, that is:

« While the communicative patterns [language] in human primates vary with socio-behavioural and geographical patterns; creativity and IQ remain constant and do not change. Intelligence and creativity cannot be stopped because of linguistic differences, since talented and gifted humans do not choose the location of their birth nor their linguistic heritage but still contribute to the enhancement of our civilisation. »

Which concludes that that the intelligence of an invidual when assessed on a range of variables [e.g. perception, fluid intelligence, artistic creativity, reasoning, emotional intelligence, courage, values, etc] cannot be deduced by simply assessing their academic abilities, since human life has various sides to itself. Hence, the true worth and value of an individual may always remain a problem and a mystery to fully assess [since most only assess people on the variables they are interested in, for e.g. a company looking for a secretary will assess the applicant on her ability to handle office politics, and not other abilities essential to exist as a human within civilisation], and this seems to go in line with Jean Piaget’s deduction about the uniqueness of the human organism and mind.

Michel-Ange-Toujours-A-Apprendre-Always-Learning

« I am still learning » – Michael-Angelo at the age of 87 / Image: La Création d’Adam (1508 – 1512)

Neurodevelopmental Disorders & Intellectual Disabilities

Neurodevelopmental disorders are disorders occurring due to the biological dysfunction of the brain that in turn lead to developmental deficits that come in a range that can be very specific to global impairment. These groups however often co-occur together, i.e. one could be affected with Intellectual Disability (ID) and also Autistic Spectrum Disorders. Psychologists are expected to show great care when assessing this group of disorder as they vary in severity. Severity has 4 Specifiers and 3 Domains [Intellectual].

Specifiers: [1] Mild – [2] Moderate – [3] Severe – [4] Profound

Domains [Intellectual]: [1] Conceptual – [2] Social – [3] Practical


Intellectual Domains

The first domain, which is the Conceptual Domain refers to all things learnt at school and required for employment and adequate independent functioning within the community. Secondly, the Social Domain refers to social, developmental and emotional factors associated to age. This manifests in them as being victims of manipulation and abuse by others. Finally, the Practical Domain refers to all skills required to live healthily [also this is subject to interpretation depending on contexts, socio-linguistic and cultural settings].

Intellectual Disability

For one to be qualified as intellectually disabled, we would have to meet all the 3 criteria below:

  • Deficits in intellectual functions, such as reasoning, problem-solving, planning, abstract thinking, judgement, learning [also from experience].
  • Deficits in adaptive functioning that means failure to meet developmental milestones within the socio-cultural standards. Limited function in daily life, participation, communication, independence in multiple environments (i.e. Global).
  • Onset is during developmental period [childhood – another link to the Psychoanalytic theory of Sigmund Freud & Jacques Lacan]


Assessment and Judgement

Careful distinction must be made when assessing patients suspected of suffering from Intellectual Disabilities (ID) between the low end of normal function and ID itself. The most widely used method clinically are IQ assessments and typically suggest any score that is 2 Standard Deviations below the mean [IQ scores of 75 +/-5] and whether the patient has had any clinical experience. Assessment based on the patient’s reasoning in real-life situations are also made. Global Developmental Delay is a term reserved for children under 5 who cannot adequately be assessed, but have missed all their developmental milestones.


Associated Features with Intellectual Disabilities (ID) to look for when diagnosing patients are:

  • Social judgment
  • Assessment of risk
  • Self-management of behaviour – interpersonal relationships and emotions
  • Motivation in school, university or work
  • Lack of communication skills and functional problem behaviours
  • Gullibility [Diagnosis is based on how people and society mistreat them – quite shocking or controversial?]
  • People with Intellectual Disabilities (ID) are also at high risk of suicide


Prevalence of Intellectual Disabilities

In the UK, 1% of people suffer from intellectual disabilities and 0.006% of the population have severe disabilities requiring supported living [that is about 360, 000 people in the UK] – a slight bias with a ratio of 1.6:1 towards males; this is due to the vulnerability of the male brain.


Autism Spectrum Disorders

As psychology evolves more consideration are being given to a dimensional aspect of abnormal behaviour rather than the usual dimensional [i.e. inflexible and sometimes exaggerated in terms of descriptive precisions disregarding individual fluctuations in symptomatic manifestations] constructs of mental disorders. Autistic Spectrum Disorders (ASD) was the first mental disorder to initiate such a shift from categories to dimensions.

  • Autistic Spectrum Disorders (ASD) with Intellectual Disability (ID) = Autism
  • Autistic Spectrum Disorders (ASD) without Intellectual Disability (ID) = Asperger’s Syndrome


Characteristics of Autism Spectrum Disorders

ASD is characterised mainly by deficits in social communication and restricted patterns of behaviour. For a diagnosis of ASD the deficits must appear early in the developmental period [however they cannot be diagnosed until the demands of a particular task exceeds the child’s capabilities] – so more severe it is the earlier it is diagnosed [e.g. Rett syndrome].


[A] Communication in ASD

In ASD, it is common to find persistent deficits in social communication and social interaction across multiple contexts illustrated by:

  • Deficits in social-emotional reciprocity, ranging from abnormal social approach. Failure to initiate or respond to social communications. Reduction in sharing interests, affect and emotions.
  • Deficits in non-verbal communicative behaviours used in normal social interactions. Abnormal or no eye contact, body language or deficits in reading [understanding] gestures. A total lack of facial expression and non-verbal communication.
  • Deficits in developing, maintaining and understanding relationships [e.g. from difficulties in adjusting behaviour to suit context]. Difficulties in sharing imaginative play or in making positive social acquaintances or friends. Hardly any interest in any form or peers.


[B] Behaviour in ASD

It is also fairly normal to notice restricted, repetitive patterns of behaviour, interests, or activities manifested by at least two of the following:

  • Stereotyped or repetitive motor movements, use of objects, or speech
  • Insistence on sameness, inflexible adherence to routines, or ritualised patterns of behaviour. Shows extreme distress at small changes, difficulty in transition, rigidity, insistence on same route taken or foods
  • Hyper or hypo-reactive to sensory inputs or unusual interest in sensory aspects of the environment (indifference or hyper-responsive to pain, temperature, sound, textures, excessive smelling to touching of objects, visual fascination with movements or lights.

ASD may also manifest itself with or without intellectual disability, with a similar scenario for language impairment, and can be associated with medical or genetic conditions or environmental factors [exposure]. ASD can also be associated with another neurodevelopmental, mental or behavioural disorder and can also comprise catatonia.
Features to look out for

  • People with ASD often have uneven profiles or abilities – even the high functioning variants, and this can lead to substantive stress for them
  • They also often have odd motor idiosyncrasies – such as an odd gait, clumsiness and abnormal ambulatory movements.
  • Disruptive, challenging behaviour and injuries are also very common
  • As sufferers of ASD age, they are also more prone to developing anxiety and depression and are likely to end up in a catatonic state


Prevalence

Autistic Spectrum Disorders (ASD) seem to be a genetic disorder, however it involves a variety of genes. 15% of ASD is due to a known mutation in over 90% of concordance studies with twins. Most researchers nowadays suggest that it is inherited and polygenic [lots of genes from genetic ancestry with each adding their weight to the likelihood of the disorder manifesting]. Males are 4 times more likely to suffer from ASD than females, and even high functioning adults with ASD have poor functioning, such as low rates of independent living and employment – older adults tend to become isolated and do not engage in help-seeking behaviours [note that this is different to individuals who may have a solitary personality by conscious choice or a highly selective social circle in personal relationships based on values, in ASD the patients are generally not conscious of the causes of their debilitating condition]

Specific Learning Disorders

Specific Learning Disorders are characterised by the following:

[A] Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that has persisted for longer than 6 months:

(1) Inaccurate or slow reading
(2) Difficulty understanding meaning in what was read
(3) Difficulties with spelling
(4) Difficulties with written expression
(5) Difficulties mastering number sense, number facts and calculation
(6) Difficulties in mathematical reasoning

[B] The affected academic skills are substantially and quantifiably below the expected level for the chronological age causing interference with academic, occupational or daily living

[C] Learning difficulties begin during school-age years, but will only manifest itself and be diagnosed when the affected person’s capabilities are stretched by demands

[D] It is also independent and not caused by another health or psychological disorder


Specifications of Specific Learning Disorder

SLD generally involves impairment in reading, writing and mathematics. If it is mild in intensity, the person can generally compensate. Moderately affected people however cannot compensate, but will respond to specialist teaching. Finally, severe conditions require specialist teaching in a specialist school as learning will not occur without such arrangements.


Features to look out for in confirming SLD

  • SLD can occur in any individual, even those classed as gifted (IQ 130+)
  • It is usually diagnosed in the early years, but in higher ability individuals it may manifest in odd ways especially when their compensatory methods are undermined
  • Patient generally have difficulties with motor co-ordination
  • It is a life-long condition and does not improve with therapy, but has to be compensated for
  • Patients also tend to have working memory deficits and keep messy environments
  • Early signs include mispronouncing words, struggling to break down words into syllables


Prevalence of Specific Learning Disorders (SLD)

SLD tend to occur in premature children or among societies with a very low birth rate. It is also more common in children with parents that smoke cigarettes [nicotine?] and is 8 to 10 times higher in families with a heritability index of 0.6 and 3 times higher in males [the vulnerability of the male brain once again]. The problems it causes with attention are likely to predict problems with the mathematical and reading components of the brain. SLD usually ends with unemployment, under-employment depression, poorer mental health and suicidal behaviour – support of any kind alters all of these outcomes.

 

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Part 2 of 5 | Anxiety Disorders

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Anxiety disorders are linked to the development of irrational fears of situations that are not life-threatening (Antony & Stein, 2009a). The avoidance of feared situations or experiences also lead to non-adaptive behavioural patterns. People suffering from anxiety disorders generally have fears accompanied by intense physiological arousal displayed by some or all of the following features: accelerated heartbeat, sweating, trembling, sensations of shortness of breath or smothering feelings of choking, chest pain, nausea, numbness or tingling, and chills or hot flushes. Other experiences of dizziness, derealisation (feelings of unreality) or depersonalization (feelings of being detached from the self) are also present in some cases.

In contemporary psychology there are a number of distinctions made between a variety of anxiety disorders based on the developmental timing of their emergence, the classes of stimuli that elicit the anxiety, the pervasiveness and topography of the anxiety response, and the role of clearly identifiable factors in the aetiology [the cause, set of causes, or manner of causation] of the anxiety.

The six main anxiety disorders are described below.


[1] Separation Anxiety

This condition most occurs in children and is generally manifested by a recurrent and persistent fear that is aroused when separation from the parents or caregivers is anticipated or imminent (American Psychiatric Association, 2000; Furr et al., 2009; Pine & Klein, 2008; World Health Organization, 1992). The persistent, excessive worry about losing, or about possible harm befalling a parent is the main characteristic of Separation Anxiety Disorder with nightmares on the similar themes also present in some cases along with recurrent head-aches, stomach-aches, nausea and vomiting. Separation anxiety is also one of the most common causes of school refusal, and sufferers may also display a refusal to sleep without being in close proximity with the parents.


[2] Phobias

Phobic anxiety is the irrational and intense fear aroused when one is faced with an object, event or situation from a clearly defined class of stimuli which is exaggerated in terms of danger posed (American Psychiatric Association, 2000; Blackmore et al., 2009; Hofmann et al., 2009; World Health Organization, 1992). When the person affected is exposed to the phobic stimulus, or anticipates its exposure, panic attacks may arise in adults whereas is children this may lead to excessive crying, tantrums, freezing or clinging. The persistent avoidance of phobic stimuli in phobias is endured with intense distress and this affects an individual’s personal functioning.

In the DSM, specific phobias are subdivided into those associated with animals, injury (including injections), features of the natural environment (such as heights or thunder), in particular situations (such as elevators or flying). These specific phobias are different from social phobias and agoraphobia.

In those affected with social phobias, anxiety is generally mainly aroused by social situations [e.g. public speaking, eating in public where there is the possibility of scrutiny by others and humiliation or embarrassment as a result of acting inappropriately]. In those with agoraphobia, the condition is known to manifest itself with panic attacks in public places, such as being in a queue, or on public transport – hence, these situations tend to be compulsively avoided to prevent the reoccurrence of the panic attacks.


[3] Generalized Anxiety Disorder

One of the main characteristics in general anxiety disorder is the constant feeling that misfortunes of various sorts will occur (American Psychiatric Association, 2000; Bitran et al., 2009; Hazlett-Stevens et al., 2009; World Health Organization, 1992) and the anxiety is not focused on one particular object or situation along with difficulties controlling the worrying process and a belief that worrying is uncontrollable.

General anxiety disorder is mainly composed of nervousness, restlessness, difficulty relaxing, feeling on edge, being easily fatigued, difficulties in concentration, irritability, tearfulness, sleep disturbance and signs of autonomic over-reactivity such as trembling, sweating, dehydrated mouth, light-headedness, palpitations, dizziness and stomach discomfort. [DSM requires some or more of those symptoms to be present]

Case Example of Generalised Anxiety Disorder

Margie, a 10 year old girl was referred to the psychologist after displaying excessive tearfulness in school, the condition which had been gradually amplifying over a number of months and the bouts were unpredictable. Margie would often end up in tears while playing with her friends during break time or when spoken to by the teacher. In the family doctor’s referral letter she was described as a worrier like her mother.

Presentation

in the assessment interview Margie explained that her worries were mainly about a routine daily activities and responsibilities, she would also worry about doing poorly at school and that she had made mistakes which would later be discovered, that her school friend would not like her, that she would disappoint her parents with the way she did her household chores, that she would either be too late or too early for the school bus, that there would not be any space for on the bus and that she would forget her school books. Her worries also extended to health with frequent stomach aches.

The safety of a family also troubled her, she would worry that her house would be struck by lightning, that the river would break its banks and flood the low-lying fens where she lived, washing away her whole house. The future was also a major concern of hers as she worried about failing her exams and being unable to find a satisfactory job, and being unable to find a marital partner or marrying an inadequate person. A continuous feeling of restlessness with the inability to relax was also reported by her.

Family History

The family was very close and Margie was the eldest of four children and the only girl. It was observed during the intake interview that the mother and the father displayed symptoms of anxiety, while the former had been treated with benzodiazepines for anxiety over a number of years. The family also admitted to regularly discuss their problems about their own health and safety and their own worries about the uncertainty of the future.

The father, Oliver was employed by the insurance company and regularly have conversations at the dinner table about the accidents and the burglaries that had befallen his client, and Margie regularly participated in these conversation, being the eldest among her siblings. However the main concern of the parents was about Margie’s tearfulness which they believed was unusual along with her worries and fears which they thought as legitimate. Margie spent a lot of time with her parents’ company but also had a couple of close friends with whom she played at the weekends.

Formulation

Margie was diagnosed with generalised anxiety disorder. The precipitating factor for the condition was not apparent as it had gradually evolved over the course of Margie’s development. The referral however, was precipitated by episodes of tearfulness at school. The predisposing factors in her case comprised of a highly likely possibility of genetic vulnerability to anxiety and exposure to family culture characterised by an excessive concern with safety and oversensitivity to dangerous situations. The ongoing parental conversations about potential threats to the family’s well-being likely maintained the condition along with inadvertent reinforcement of Margie’s tearfulness at school, where her tears were responded to with considerable concern.

The protective factors in the case included good premorbid adjustment, the parents’ and the school’s commitment to solving the problem and the availability of peer group support. [This formulation is diagrammed below]

General Anxiety Disorder Formulation

Treatment

In this particular case, treatment involved family work focused on helping Margie parents reduce the amount of time they spent discussing themes related to danger and threats to their health and safety, and increase the amount engaged in activities and discussions focused on Margie’s strengths and capabilities. The parents were also assisted in coaching Margie into learning relaxation skills and mastery oriented coping self- statements. Eventually Margie showed improvement in her adjustment in school with some reduction in anxiety and tearfulness.

[4] Panic Disorder

In panic disorders, there are recurrent unexpected panic attacks; an ongoing primary fear of further attacks; secondary fear of losing control, going insane, having a heart attack or dying (American Psychiatric Association, 2000; Ballenger, 2009; Hofmann et al., 2009; World Health Organization, 1992). Acute episodes of intense anxiety our experienced in panic attacks, and these reach a peak within 10 minutes. They are characterised by autonomy hyper arousal shown by some of the following symptoms:

– Palpitations

– Sweating

– Trembling or shaking

– Shortness of breath

– Feelings of choking or smothering

– Chest pain or discomfort

– Nausea or abdominal distress

– Dizziness

– Chills or hot flushes

– Parasthesias (Numbness or tingling sensations)

– Derealisation (Feelings of unreality)

– Depersonalisation (Feelings of being detached from oneself)

In panic disorder, patients tend perceive normal fluctuations in autonomic arousal as a stimulus that provokes anxiety, with the belief that these may signal the onset of a panic attack. During a panic attack, patients typically tend to report an irresistible urge to escape the location where the attack occurred and to avoid such situations in the future. Public settings are usually the most common location where panic attacks take place [e.g. queues, public transport, shopping mall, etc] and acute autonomic arousal is only alleviated upon escape from these places or situations – hence secondary agoraphobia often develops when the patient fears leaving the safety of their homes in case of panic attacks occurring in public settings.

[5] Posttraumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) tends to occur after a catastrophic trauma such as a terrorist attack, an armed combat/robbery, a natural or man-made disaster, a serious accident that was perceived to be potentially life-threatening for oneself or others, torture, child abuse or rape.

PTSD is mainly composed of:

– Recurrent intrusive traumatic memories

– Intense anxiety in response to these memories and ongoing hyper arousal in anticipation of their recurrence

– attempts to regulate anxiety and hyper arousal by avoiding cues that trigger traumatic memories and attempts to suppress these memories when they intrude into consciousness (American Psychiatric Association, 2000; Ehlers, 2009; Friedman, 2009; World Health Organization, 1992).

Recurrent, traumatic memories include flashbacks, nightmares, or repetitive trauma themed play in the case of children, and these occur in response to internal (psychological) or external (environmental) cues that symbolise the traumatic event or aspects of it. Since patients with PTSD tend to anticipate the recurrence of traumatic memories, they experience chronic hyper-arousal which may in turn lead to difficulties in concentration, sleep difficulties, hyper-vigilance and irritability. In PTSD, the attempts to suppress traumatic memories and the avoidance of trauma-related situations may turn out to be unsuccessful, when such a scenario occurs, the PTSD person generally experiences an increase in the frequency and intensity of past traumatic memories. Emotional numbing is also quite common in chronic cases due to the frequent attempts to keep the trauma-related memory out of consciousness – this eventually leads to the inability to recall the traumatic memories. To some this may seem like a solution but the cost is excessive since emotional numbing does not only result in the exclusion of trauma-related emotions such as anxiety and anger out of consciousness, but also tender feelings such as love and joy – which cease to be experienced by the patient.

PTSD may also lead to a subjective sense of foreshortened future to the patient and this may also be accompanied by limited involvement in his/her usual activities.

[6] Obsessive Compulsive Disorder

Obsessive Compulsive Disorder (OCD) is generally characterised by distressing obsessions and compulsive rituals that reduce the anxiety associated with those obsessions [like 2 opposing forces] (American Psychiatric Association, 2000; Matthews, 2009; World Health Organization, 1992; Zohar et al., 2009). Obsessions are stereotyped thoughts, impulses or images that are recurrent and persistent. These cause serious anxiety to the patient since they are experience as senseless, uncontrollable and involuntary, and are linked to issues such as obscenity [this does not mean that healthy people with normal sexual feelings in healthy relationships have OCD], violence and danger [for e.g. some people suffer from irrational fears of the possibility of a catastrophe occurring unless symmetry or order is maintained, or there may be fears of losing control and violently raping or assaulting others, or fears of contamination [hygienic].

These compulsions are ritualistic and repetitive accompanied by stereotyped behaviours such as hand washing, ordering and checking or mental acts such as repeating words silently [which some patients feel compelled to do to regulate the anxiety caused by the obsessions], counting or praying [this should not lead to the belief that all people with faith in God suffer from OCD]. Compulsions are generally excessive attempts or unrealistic ways to avert imagined dangers entailed by these recurrent obsessions that are debilitating and are usually recognized as pointless while repeated attempts are made to resist them [once again this seems to be linked to the unconscious yet active component of mental activity and yet again leads us to Sigmund Freud and Jacques Lacan].


Clinical Features of Anxiety Disorders

The 6 anxiety disorders listed above are classified into the domains of Perception, Cognition, Affect, Arousal, Behaviour and Interpersonal Adjustment. In regards to perception, the disorders vary in the classes of stimuli that elicit the anxiety in the patient.

i)Perception

In cases of Separation Anxiety, the separation itself is the stimulus. Where phobias are the condition present, it is specific creatures [e.g. animals], events [e.g. injury], or situations [e.g. meeting new people] that trigger the anxiety. With Generalized Anxiety Disorder [GAD], the interpretation of multiple aspects of the environment end up being interpreted as potentially threatening. Panic disorder is characterised by somatic sensations of arousal such as tachycardia being perceived as threatening since they are treated as the signals that lead to full-blown panic attacks. In people with PTSD external and internal cues that bring back memories of the trauma that led to the condition elicit anxiety. In Obsessive Compulsive Disorders (OCD) stimuli that evoke obsessional thoughts elicit anxiety [e.g. potentially dirty environments or situations may give rise to obsessional ideas about hygiene and cleanliness, and anxiety about contamination.

ii)Cognition

It is important to note that in all 6 of those listed anxiety disorders, that the central organizing theme around cognition is “detection and/or avoidance of danger”. In children with Separation Anxiety there is the irrational belief that the caregivers or parents will be harmed if the separation occurs. In people affected by Phobias there is a constant fear of being harmed by either the feared object or creature, or being in the feared situation [e.g. being bitten by a god – in the case of Dog Phobia OR being negatively judged by meaningless strangers that have no connection or impact on the life of the patient in the case of Social Phobia]. As for Generalized Anxiety Disorder (GAD), patients tend to catastrophize about any features of their environment [e.g. fears of their house being burnt down, or that they will be the victim of a car crash, or punishment for some wrongdoing, they will be forsaken by those they consider as friends, and so forth – they also believe that their worries are uncontrollable. In Panic Disorder, there is the belief that more panic attacks are imminent and that they might be fatal to the patient. In many cases secondary agoraphobia also develops as they individual develops the belief that remaining in the safety of their homes might lower the probabilities of suffering from a panic attack. As for PTSD, there is the belief that as long as the intrusive memories of the trauma are forced out of consciousness, the danger of re-experiencing the intense fear, distress and horror associated with the traumatic event that led to the condition of PTSD can be avoided. Obsessive Compulsive Disorder (OCD) generally leads to obsessions mainly concerned with dirt and contamination; catastrophes such as fires, illness or death; symmetry, exactness and order; religious scrupulosity; disgust with secretions and bodily wastes [e.g. urine, saliva or stools]; lucky or unlucky numbers and extreme, wild, violent and even dangerous sexual thoughts [risk-taking] – the neutralisation of the threat posed by specific obsession-related stimuli is believed to be achieved through being engaged in specific rituals.

iii)Affect

In all 6 of the mentioned anxiety disorders affective states generally follow the beliefs about threat and danger, and these are characterized by feelings of uneasiness, restlessness and tension. In the case of OCD, outbursts of anger may occur if the patient is restricted from executing his/her compulsive rituals or if compelled to approach the feared stimuli; and in children with Separation Anxiety Disorder (SAD) may display aggressive tantrums if compelled to stay in school without their caregivers or parents. In Post-Traumatic Stress Disorder (PTSD), on top of the affective experiences of tension and uneasiness, emotional numbing arises from repeated attempts to exclude all affective material from consciousness.

iv)Arousal

The pattern of physiological arousal varies depending on the frequency of contact with the feared stimuli. In Separation Anxiety Disorders (SAD), hyper-arousal only occurs when separation is anticipated or imminent. In the case of Specific Phobias hyper-arousal only manifests in the present of the feared object or animal. In General Anxiety Disorder (GAD), a pattern of ongoing hyper-arousal can be observed, while in Panic Disorder and PTSD it is moderate followed by brief episodes of extreme hyper-arousal – these occur during attacks in Panic Disorder and when memories of the traumatic event intrude into consciousness in PTSD. In the case of OCD, specific cues related to the obsessions evoke acute and intense episodes of arousal.

In somatic symptoms the extent to which physiological arousal finds expression varies, for e.g. recurrent abdominal pain and headaches are quite common in Separation Anxiety. Sleep problems also occur in most Anxiety Disorders. In Panic Attacks it is also common to notice full blown attacks with sweating, feelings of choking or smothering, shortness of breath, trembling, nausea, dizziness, chest pains, hot flushes or chills, parasthesias, depersonalization or derealisation.

v)Behaviour

All Anxiety Disorders are characterized by avoidance behaviours, and in Specific Phobia, avoidance may even lead to a constriction in lifestyle [using an Injury Phobia as example, the patient may refuse to take part in any form of physical activity [e.g. sports] or ride a bicycle]. In other cases, the patient sometimes become house bound due to his compulsive avoidance, and this generally occurs in Separation Anxiety Disorder, Generalized Anxiety Disorder, Panic Disorder and PTSD. In those with PTSD, the use of alcohol or drugs to alleviate negative affect and suppress traumatic memories is quite common; and in OCD the patients generally engage in compulsive rituals in a desperate effort to regulate their anxiety associated with obsessional thoughts [it may be fair to note the relation between the Anxiety [as the Signifier] and the Obsessional Thoughts [as the Signified] in a Lacanian perspective here to point out the logic behind the flamboyant Frenchman’s model of Mental Activity based on Freud’s initial Topological Model – the Unconscious, the Preconscious and the Conscious]. These compulsions in OCD genereally include washing, repeating a particular action, checking, removing contaminants, touching, ordering and collecting.

vi)Interpersonal Adjustment

All 6 Anxiety Disorders affect interpersonal adjustment in a precise manner. In cases of Simple Phobia, interpersonal difficulties arise only in those situations where the individual does not conform or co-operate with normal activities [deemed social] so as to avoid the feared stimuli [e.g. a brief episode of marital conflict may occur if a husband refuses to enter an elevator at a shopping mall because of his claustrophobia]. Separation Anxiety Disorder (SAD), Panic Disorder (PD), Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD) sometimes prevent young people from attending school or adults from attending work, and in all those situations friends or family relationships may be seriously compromised. In the case of OCD peers or relatives may sometimes attempt to reduce the sufferer’s anxiety in participative actions in the compulsive rituals or in other cases, they may also exacerbate the anxiety by punishing the patient for his or her compulsive behaviour. In extreme cases, these compulsions can become so extreme that the affected person becomes constricted.


Epidemiology, Risk Factors and Course of Anxiety Disorders

Anxiety Disorders are the most common types of psychological disorders, and the lifetime prevalence rate in adults in the US National Comorbidity Survey Replication was 28.8% (Kessler et al., 2005). There is a consensus that Phobias are the most prevalent anxiety disorders and OCD is the least prevalent across a wide range of epidemiological studies (Kessler et al., 2009; Furr et al., 2009). For Phobias, lifetime prevalence estimates range from 6% to 12%, whereas those with OCD fall below 3%. Generalized Anxiety Disorder (GAD) has a lifetime prevalence of 1% to 6 %, whereas Panic Disorder in adults and Separation Anxiety in children range from 2% to 5%. In National representative samples, the prevalence of PTSD ranges from less than 1% or 2% in Western Europe to almost 8% in the US. The great variability is believed to be due to the fact that PTSD rates depend on the prevalence and traumatic exposure within specific locations geographically and the vulnerability of the populations within these countries to developing PTSD – in populations exposed to terrorism the prevalence is 12% – 16% (DiMaggio & Galea, 2006).

In people suffering from Anxiety Disorders, there is also a high risk of comorbidity [i.e. other anxiety disorders may also be present], and up to 1/3 of those suffering from Anxiety Disorders also suffer from another (Kessler et al., 2009) – they may also occur comorbidly with mood disorders in adults as well as children, substance use disorder in adults and adolescents and disruptive behaviour in young people/children (Furr et al., 2009; Huppert, 2009; Zahradnik & Stewart, 2009).  In cases where substance misuse is also present, the use of drugs or alcohol is quite common in managing anxiety.

OCD is also present in a significant proportion of people with eating disorders such as anorexia nervosa. (Halmi, 2010).

We can observe a clear age and gender difference in the prevalence of Anxiety Disorders (Antony & Stein, 2009a; Furr et al., 2009; Kessler et al., 2009) and across most studies that are available, the modal age of the onset in Separation Anxiety Disorder and Specific Phobias is during the developmental phase in childhood [a stage pointed out by both great Western psychotherapists, Freud and Lacan, and also John Bowlby in his observational research on the development of attachment types in children at this critical stage of development], whereas that of anxiety disorders generally happens during adolescence or adulthood. In both adults and children, there is a tendency for more females to suffer from Anxiety Disorders than males, with the exception to this balance being for OCD which has a similar number men and women suffering from the condition although it is the rarest of anxiety disorders.

Anxiety Disorders tend to show a recurring episodic course with a gradual reduction in prevalence over the course of the life cycle (Kessler et al., 2009). It is also worthy to note that most children with anxiety disorders do not grow up to be adults with anxiety disorders or depression, however most anxious adults do have a history of childhood anxiety disorders. There are a number of risk factors associated with Anxiety Disorders and these include anxiety disorders or psychological disorders in the direct genetic network, an inhibited temperament of behaviour, neuroticism as a trait of personality, a personal experience of psychological problems, a history of over-controlling or critical parents, a history of conflict and violence and a history of stressful life events (Antony & Stein, 2009b; Pine & Klein, 2008). In the scenario of Anxiety Disorders, a behaviourally inhibited temperament is generally the tendency from birth – to become nervous and withdrawn from unfamiliar situations and stimuli. Neuroticism is a trait of personality that gradually develops over the life-span, and it is characterized by the tendency to escape negative affect and includes hostility, anxiety and depression in its manifestations.

In those suffering from Post-Traumatic Stress Disorder (PTSD) the additional factors that increases the risk for development include the severity of the trauma, high-life stress following the trauma, low socio-economic status, low support [from friends or those considered as friends], low intelligence and low educational level (Ehlers, 2009; Ozer et al., 2003). In PTSD, dissociative experiences tends to refer to abnormalities of perception, memory or identity such as derealisation [seeing the world as dream-like], depersonalization [seeing oneself from an external perspective or inability to recall important information]. In the case of parents with PTSD, their children are also at a higher risk of developing the disorder (Pine & Klein, 2008).

 

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Part 3 of 5 | Depression

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The states of being happy or sad are adaptive feelings, and many behaviours that lead to happiness among human beings, such as socializing [with the people that matter to the subject], becoming completely absorbed in productive work and developing longstanding friendships that are meaningful around values and loyalty, are important not only for the emancipation of the individual but also for a harmonious and functional society that embraces the « humane » qualities of mankind in all its creative aspects.

Sadness on the other hand is a psychological state commonly preceded by loss [of various kinds, which may range from material objects to valued relationships or abilities/skills and status related to them through accident or disease or other situations], and it is a negative feeling which may also be adaptive, in a sense that it is a reminder to most people [at least for those who are NOT philosophically oriented / cultured or have an understanding of values and loyalty in interpersonal relationships], that valued things or people need to be taken care of if they do not want to lose them in the future, especially the common volatile brain [i.e. the basic Darwinian instinct-guided average brain that lacks reflective abilities, reasoning skills, intuition and insight, while also failing to realises or understand the motivation behind its behaviour until matters have taken a disastrous course]. Sadness is also a way of signalling to others that we as human beings also need care and elicits [to most psychologically healthy human beings with a theory of mind] support that soothes our emotional pain – this is what makes us a superior breed of primates, i.e. our ability to reason and evolve with emotions as a propulsive form of energy for both individual and group, like Alexandre Dumas put it, “Un pour tous et tous pour un!” [French for “One for all and all for one!”].

Some extreme states of mood such as depression and mania are less adaptive than happiness and sadness; and it is now commonly known that during periods of hypomania or mania some patients suffering from Bipolar Disorder [which is characterized by episodes of mania and depression] produce highly creative artistic work (Silvia & Kaufman, 2010). This should not lead us to the conclusion that ALL creative people with extreme ways of exploring and expression their emotions through art suffer from Bipolar Disorder. But for those who do suffer from Bipolar Disorder and produce creative work, this highly valued asset comes at a price, since these individuals generally involve themselves in high-risk behaviours that come with the possibility of severe dehydration and exhaustion during manic episodes.

Seasonal Affective Disorder [or Winter Depression, its colloquial name] is a condition that is believed to be linked genetically to our cave-dwelling ancestors from the prehistoric era, who may have hibernated – an adaptive behaviour for the ancestors. However, in the world of today, depression does not seem to serve any adaptive function, and despite this, it remains a highly prevalent condition that affects up to 25% of the population (Kessler & Wang, 2009); because of this prevalence the main focus of this section will be on Major Depressive Disorder.

Share of population with chronic depression

Share of the population reporting that they had chronic depression / Source: EuroStat

It is quite fundamental to grasp that depression is not simply “feeling sad”, as Major Depressive Disorder is an ongoing condition characterized by episodes of low mood and loss of interest in pleasurable activities along with other symptoms such as poor concentration, fatigue, pessimism, suicidal thoughts, and sleep and appetite disturbance. Depression is a serious public health concern because it radically decreases the quality of life of those affected, is a huge economic burden in terms of reduced productivity [and lack of creativity] among the national work force, and it also has adverse effects on the mental health and adjustment of the children of the depressed people (Garber, 2010; Kessler & Wang, 2009). This section will focus on the clinical features, epidemiology, risk factors and course of depression [suicidal risks will also be discussed].


Clinical Features of Depression

Severity

Depression can be classified as mild, moderate to severe, depending on the degree of impairment

Melancholia

In regards to somatic or melancholic features, in severe depression where there is a loss of pleasure in all activities [known as anhedonia] and a lack of reactivity to pleasant stimuli along with diurnal variation in mood and sleep and appetite disturbance, we tend to qualify such episodes as having melancholic features. Historically [please take note that this is not the case anymore], there was an ongoing view that these symptoms reflected “endogenous”, a genetically determined and biologically based form of depression, as different to a “reactive” depression arising from exposure to stressful life events and environmental adversity (Monroe et al., 2009).

However, the difference between these 2 forms of depression was not supported by empirical research, which instead shows that ALL episodes of depression are preceded by stressful life events, and that in any given scenario, we tend to have a combination of genetic vulnerability and environmental adversity that contribute to the development of depression (Parker, 2009).

Psychotic Depression

When mood disrupting delusions and hallucinations are present, depressive episodes are described as having psychotic features. Mood-congruent delusions are generally firmly held beliefs that are extremely pessimistic in nature and that have no basis in reality [illogical and cannot be explained and justified; for e.g. that a completely innocent individual is guilty of many wrongdoings and deserve to die. Mood-disrupting hallucinations in depression are generally auditory and sometimes involve the hearing of voices in a complete absence of any form of external stimuli [uncontrolled and unimagined and ongoing for months], which has negative advices to the sufferer [e.g. You are a failure, you are guilty of wrongdoing, or evil].

Among children, adolescents and adults, there has been a range of clinical features identified through both clinical observation and empirical research (e.g. Bech, 2009; Brent & Weersing, 2008; Gotlib & Hammen, 2009; Nolen-Hoeksema & Hilt, 2009a). Common clinical features of depression tend to affect the domains of cognition, perception, mood, somatic state, behaviour and relationships. Loss is once again a main thematic feature in depression as pointed out by Psychoanalytic Theories [loss of any kind, e.g. material, emotional, relationship, valued attribute due to sickness/accident, health, etc], and clinical features may be linked to those different domains of mental life.

Perception

In regards to perception, depressed individuals who have suffered some form of loss [internal or external] tend to perceive reality and the world as one where further losses are possible, and individuals who suffer from depression also selectively attend to negative stimuli and features in the environment. This leads them to engage in further depressive cognitive patterns in their thoughts processes and unrewarding behavioural patterns which amplify their depression’s severity – in cases of severe depression, mood-congruent auditory hallucinations are often reported. Hence, depressed people or people with depressive personality traits tend to come across as repulsive and despicable because of their obsessive disposition to only perceive the negative side of everything and every situation that life has to offer [note: this is different to constructive criticism which is normally for a purpose and comes with systematic reasons for enhancement]. Psychologists tend to go with the assumption that such severe perceptual abnormality is present only when patients report hearing harsh critical voices or containing depressive contents [as mentioned above]. These auditory hallucinations are also present in schizophrenia, however they are not always mood-congruent like in depression.

Cognition

Depressed patients tend to describe the world and the fabric of reality of their subjective experience in negative terms, this also include descriptions of themselves and their abilities [e.g. occupational and social accomplishments] – this negative evaluation is often portrayed as guilt for not living up to the standards [they set themselves based on their ‘perceived’ abilities] or for letting others down. They sometimes perceive their direct environments [peers, network, family, work colleagues or school/university] as hostile, apathetic, critical and unrewarding. The future is also described in very bleak terms by those suffering from depression, and they also report little if any hope that matters will improve. When extreme hopelessness is reported is it usually accompanied with excessive guilt for which the patients believe they should be punished – suicidal ideas and intentions may also be declared. In depressive delusional systems, extremely negative thoughts about the self are generally reported with the world and their future entangled in them.

Besides the content and thoughts being incredibly negative and bleak, depressed patients also tend to display concentration problems and logical errors in their thinking. These mistakes in reasoning are also characterized by a tendency to maximise the significance of negative events and minimize the significance of positive ones. Depressed patients also suffer from memory problems and struggle to remember happy events but instead have global over-general autobiographical memories about both positive and negative events. In addition to these, this category of patients also suffer from concentration, attention and decision-making problems that in turn give rise to difficulties managing leisure activities requiring sustained attention and academic or occupational responsibilities.

Affect

The impact on the patient’s affect tends to lead to low mood, and diurnal variations in mood and anhedonia. The depressed mood is usually reported as a feeling of sadness, loneliness, emptiness and despair. Diurnal variations in mood is usually quite common in severe cases of depression, with the patient’s mood generally being worse in the morning or after waking up. In cases of major depression, as a person moves from mild to moderate to severe depression, the increasing number of symptoms along with the intensity can also lead to intense anxiety. Generally, fears are experienced in the form of “Will this get worse? Am I stuck in this living hell forever? Will I ever be myself again? Will I be able to prevent myself from committing suicide to escape? Irritability is also a characteristics of depression, with the patient sometimes expressing their anger at the source of their loss [e.g. anger at a deceased one for abandoning the grieving person or sometimes at the health professional for not being able to alleviate their depressive symptoms].

Somatic State

The changes in the patient’s somatic state associated with depression include the disturbances of sleep and appetite, the loss of energy, failure to make age-appropriate physiological growth, weight loss, pain symptoms and a loss of interest in sexual activities. Commonly, depressed people struggle to find sleep and eat insufficiently due to their poor appetite; these symptoms are known as vegetative features. The sleep disturbances in depressed people generally involve problems trying to sleep, wakefulness at night or early-morning sleep disruption. Other symptoms such as racing thoughts and engaging in depressive rumination while unable to sleep is also quite common. In atypical cases of depression, patients may sometimes oversleep due to a constant feeling of exhaustion and consume excessive food due to an increased appetite or due to the feeling that eating may temporarily reduce their distress.

Medically unexplained chest, abdominal and back pain along with headaches are some of the additional features of depression. In some cases the pain symptoms are some of the first signs that would be reported to the doctor and it is only when the medical investigations of these symptoms turn out to be negative that depression is suspected to be the cause. All the somatic symptoms mentioned are consistent with research: dysregulation of neurobiological, endocrine and immune functions is associated with depression and the sleep is also affected.

Behaviour

Depressed patients are characterized behaviourally by the reduced and slow activity levels [psychomotor retardation] that they display, and are often helpless [without any control over their abilities] about their inability in getting involved in activities that could have helped their condition by bringing a sense of achievement or connectedness to meaningful [those chosen by the individual as a person with significance to him/her – note that it is a choice] people in their life. In rare cases some individual become house bound and immobile; such a condition is known as depressive stupor.

One of the major risks of depression is self-harm [a clear distinction is made between non-suicidal deliberate self-harm and suicidal behaviour]. In non-suicidal tendencies, patients may cut or burn themselves to distract themselves from the depressive feelings. In some cases, some have taken non-lethal overdoses to elicit attention and care from their close ones or to simply gain admission to hospital and remove them from the stressful situations that may have been amplifying their depressive symptoms.

Relationships

Depressed patients generally report a deterioration in their relationships with a range of significant figures in their lives from a wide range of environments [from professional to personal], and describe themselves as lonely, unable or unworthy to take steps to try and engage in some form of contact with others. Surprisingly, when the depressed attempt to overcome their loneliness by talking to others, they tend to come across as repulsive, unpleasant and draining through their depressive behaviour, pessimistic belief and sometimes arrogant narcissistic talks, this drives away those they interact with.


Epidemiology, Risk Factors and Course of Depression

The most common mood disorder is Major Depression, and it has a lifetime prevalence rate of 6 – 25% in international community studies (Kessler & Wang, 2009). In the US National Co-morbidity Survey Replication the lifetime prevalence of DSM-IV Major Depression was 16.6% (Kessler et al., 2005). It is good to note that Depression is less common among pre-pubertal children than adolescents and adults (Brent & Weersing, 2008). Among children the number of boys to girl with depression is equal, however this changes in adolescence and by adulthood; compared with men, about twice as many women have depression (Nolen-Hoeksema & Hilt, 2009b).

In most cases of depression, there are many comorbid disorders also present. In the US, National Comorbidity Replication Survey, 59% of depressed patients suffered from comorbid anxiety disorders and 24% had comorbid substance use disorders (Kessler & Wang, 2009). Depression also tends to follow a chronic relapsing course, with up to 80% of people suffering from recurrent episodes, and it has been found that the median duration of episodes in community samples typically lasts for about 5-6 weeks. In clinical samples depressive episodes tend to last for about 5 to 6 months; the majority of cases however recover within 1 year and about half of patients continue to suffer from fluctuating residual symptoms between those depressive episodes; and for less than 10% of patients, recovery does not occur and chronic depressive symptoms persist and most cases relapse within 5 years (Angst, 2009; Boland & Keller, 2009).

During treatment, as more depressive episodes occur, we tend to notice a decrease in inter-episode intervals and a reduction in the amount of stress required to trigger the onset of further depressive episodes, an issue related to Stress Theories (Boland & Keller, 2009).

NOTE: Stress theories propose that individuals develop depression following exposure to stress. The diathesis- stress theories propose that depression only follows after exposure to stress in people who have specific biological or psychological attributes that render them more vulnerable to stressful life events, and the most vulnerable require the least stress to trigger depression (e,g., Joiner & Timmons, 2009: Joormann, 2009; Levinson, 2009). On the other hand, Stress-generation theory proposes that people with certain personal attributes inadvertently generate excessive stress, which in turn leads to depression (Liu & Alloy, 2010)

The risk factors for depression include a family history of mood disorders, female gender, low socio-economic status involving educational and economic disadvantage, and adverse early family or institutional environment, the depressive temperament, a negative cognitive style, deficits and self-regulation, high levels of life stress, and low levels of support from meaningful others (Garber, 2010; Hammen et al., 2010).

Risk factors for recurrent major depressive episodes identified in the US collaborative depression study of 500 patients, include a history of three or more prior episodes, comorbid dysthymia (often known as Double Depression), comorbid anxiety and substance use disorders, long duration of individual episodes, poor control of symptoms by antidepressant medication, onset after 60 years of age, the family history of mood disorder, and being a single female (Boland & Keller, 2009).

Four small category of people who suffer from depression, deficits the visual processing of light and the season of the year are risk factors for depression (Rosenthal, 2009). These people, who experience regularly recurring depressive episodes in the autumn and winter, with remission in the spring and summer, are generally considered as suffering from Seasonal Affective Disorder. These patients develop symptoms in the absence of adequate light and respond positively to enhanced environmental lighting, often referred to as “Light Therapy or Treatment” (Golden et al., 2005).

In community samples about 3.4% of people with major depressive disorder commit suicide; the rate in clinical samples about 15%; about 60% of completed suicides (studied by psychological autopsy) had suffered from depression (Berman, 2009).

 

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Part 4 of 5 | Schizophrenia

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Before covering the topic of schizophrenia, it is important to take note that the condition is commonly confused to refer to another condition that involves split-personalities, and this is mostly a trend that lives in the world of pop culture and Hollywood. About 40% in the UK equated split or multiple-personality with schizophrenia in a National Survey (Luty et al., 2006). However, after covering this section, we hope that the confusion will be cleared since schizophrenia does not refer to conditions that involve split-personalities [the closest scientific equivalent to this state of being, is a condition known as Multiple Personality Disorder or Dissociative Identity Disorder and are both not as debilitating as schizophrenia with treatment being much more effective].

Schizophrenia refers to a collection of seriously debilitating conditions characterised by positive and negative symptoms in this organisation (Mueser & Jeste, 2008).

Delusions and hallucinations are the principal positive symptoms of schizophrenia. Delusions are strongly held, unfounded, culturally alien beliefs. For example with persecutory delusions, individuals may believe that a group of people conspiring to harm them [this should not lead us to believe that a healthy person with a suspicion caused by the critical analysis of a person or group of people is deluded and is schizophrenic – remember that human beings have individual personalities too]. Hallucinations on the other hand involve experiencing sensations in the absence of external stimuli [e.g. with auditory hallucinations – which are the most common type in schizophrenia – people reported hearing voices that others cannot hear].

The negative symptoms of schizophrenia include flattened affect, alogia and avolition. In the case of flattened affect, the emotional expression of the patient is limited, and with alogia there is an impoverished thought that is inferred from the patient’s speech. Short brief and concrete replies are given to question [this is referred to as poverty of speech], or in some cases speech production is normal but it conveys little meaning and information due to repetition, or being overly abstract [referred to as poverty of content], or being too concrete. When patients suffer from avolition, a lack of goal directed behaviour can be observed. The negative symptoms generally give rise to a restricted lifestyle involving little activity, little social interaction with others and little emotional expression – disorganisation may also affect both speech and behaviour [disorganised, illogical, incoherent, speak are the signs of an underlying formal thought disorder]. Disorganised catatonic behaviour is usually characterised by the complete absence of spontaneous activity or excessive purposeless activity.

Schizophrenia is a debilitating and re-occurring condition that comprises the capacity to carry out normal activities, and also consists of incomplete remission between episodes.  (Hafner & der Heiden, 2008). Symptoms of schizophrenia typically appear in late adolescence or early adulthood, wax and wane over the life course, and have a profound long-term effect on patients and sometimes their families.

Schizophrenia is considered to be the most debilitating of all psychological disorders, since it affects the patient’s capacity to live independently, make and maintain satisfying and enduring relationships, engage in family life, parent children effectively, work productively and enjoy leisure activities. Rates of unemployment, homelessness and imprisonment are very high among people with schizophrenia, although just under 1% of people suffer from schizophrenia, the World Health Organization has rented as second only to cardiovascular disease in terms of overall disease burden internationally (Murray & Lopez, 1996).

Despite these unattractive facts, the scientific advances in our understanding of schizophrenia, along with advances in both psychological and pharmacological approaches to treatment, making it increasingly realistic for people who suffer from schizophrenia to live far more productive lives than were previously possible (Mueser & Jeste, 2008).


Case Example of Schizophrenia

A young man, named Julian was referred for assessment and advice by his doctor. Since returning to his rural home after studying in London for one year, his parents started to worry about his state because of his strange behaviour. After failing as exams, the patient said that he had to ”sort his head out”. Since his return, the parents had noticed a lack of concentration along with incoherent speech during his conversations which happen most of the time – his behaviour was also erratic and unpredictable.

The parents concern grew when Julian suddenly went missing a few weeks prior to the referral. After hours of searching, he was found about 55 Km from their home, dehydrated, exhausted and dressed only in sport shorts, singlet and running shoe. After enquiry, the latter developed the belief that a secret mission in the East had to be undertaken by him; and as he started jogging in the morning, he headed eastwards towards the rising Sun. He even planned to jump onto the car ferry when he reached the coast, across the sea over to Holland, and continue east towards India in his secret mission [reminiscent of a James Bond episode].

Since the episode, Julian has spent much of the time in his room muttering to himself, often becoming quite distressed, and when his parents spoke to him they found it hard to make any sense out of his words.


Family History

Julian was the 19-year-old son of a prominent farmer in a rural English village where the whole family lived in a large amount on an extensive estate. The farm was managed by the patient’s father; who had a traditional authoritarian manner and a positive, if distant, relationship with Julian. While he was incredibly worried about Julian and to the search for him, once the latter was found, the father returned to work unless the care of his son to his wife.

The mother was an artist who dressed flamboyantly, behaved in a theatrical manner and held century, unconventional beliefs [e.g. Conspiracy theories about many issues, was interested in eastern mysticism and believe that faith healing and alternative medicine were preferable to traditional Western medicine]. These characteristics of a personality along with her beliefs affected her treatment of Julian after the ”Running East” episode, where she engaged the latter in intense conversations about mystical meaning of the psychotic experiences that led to him trying to make his way to India on foot. Rather than taking Julian to the accident and emergency department of the local hospital for assessment, she brought him to a feeler and then than homeopathist. It was only of these interventions failed to our view the distress that she took Julian to the doctor, who made the referral to the community mental health team. In the preliminary assessment that was conducted with Julian and both of his parents, the mother responded to the son with intense emotional over involvement (an index of high expressed emotion associated with a relapse in schizophrenia; Hooley, 2007).

With regard to the extended family, according to parents there has never been a family history of psychological disorder. However some members of the mother’s well-to-do family were fairly eccentric and odd, especially her brother, Sedric, and her uncle, William Jr. Williams eccentricities led him into serious conflict with his father, and Sedrick’s odd behaviour underpin his highly conflictual, childless marriage.


Developmental history

Julian on a family farm and went to the local school, his development was what most people would call normal. His Academy former school was above average and he had many friends in his local village, and was a popular child and adolescent who also excelled at cricket. At 18 years old before going to university London, he had no psychological problems.

His first term at college was successful academically and socially, however, the occasional experimental cannabis use that had begun the summer before going to college turn to a regular use once Julian moved to London. During his time at university, the patient also experimented with LSD on a few occasions. In the final term of his first year at college, Julian developed intense fear of exam failure. Other symptoms quickly followed such as difficulty studying effectively and sleeping problems. Julian stopped attending classes regularly and spend more time alone, and was relieved to return home after sitting as exams. Once home he was described as quiet and thought during most of the time prior to the “running East” episode.


Presentation

Julian presented with symptoms such as delusions, hallucinations, disorganised speech and anxiety. At the very start the patient was very reluctant to be interviewed because he believed he had urgent business to attend to in Holland and further afield in India. He also showed signs of being anxiously distressed throughout the interview, explaining that his path was to the east and believed he was being called there by an unknown source. He firmly believes this because of a sign he had seen while out jogging on the morning of the enigmatic “running East” episode. The way in our God will record the sunlight and cast a shadow on the red barn against which it was leaned made a distinctive pattern, which to him meant a special sign indicating that he should go East, first to Holland and then all the way to India. Upon questioning this idea, a clear authoritative voice said that he should leave at once.

At this point in his narrative, stopped mid-sentence and displayed thought blocking, and will strive the topic he was talking about. Upon being asked to continue his story, he began to giggle, and when questioned about the reason behind his amusement, Julian declared to have heard someone say something funny. Julian then spoke about a number of unrelated topics in an incoherent way before experiencing thought blocking again.

Later he expressed the desire to leave soon because people will try to prevent him, as he had heard them plotting about this the day before, and also declare that they had tried to put bad ideas into his head [which he described as frightening]. He was also frightened by periodic sensations that everything was too loud or too bright and coming at him, declaring “it was like doing acid [LSD] all the time… a really bad trip.”


Formulation

In Julian’s case he presented with auditory hallucinations, delusions, thought disorder, anxiety and a significant deterioration in social and occupational functioning which had been present for more than 1 month [symptoms consistent at the time of this essay with a diagnosis of Schizophrenia]. The patient also showed a complete lack of insight and was unable to understand that the voices being heard were hallucinations and that the delusional beliefs were unfounded. Among the major precipitating factors were the experience of recent exam pressure and his transition from living at home to living in London at attending college. The principal predisposing factors were possible genetic vulnerability to psychosis and a history of hallucinogenic drug use.

His psychological condition was maintained by what was likely to be an excessive level of maternal expressed emotion characterised mainly by emotional over-involvement. His delusions were also reinforced by the mother since the latter engaged Julian in long and draining conversations about them. The protective factors in this case were godo premorbid adjustment and a strong family support for the boy.


Treatment

The treatment plan included antipsychotic medication and family will to reduce parental expressed emotion, with an initial brief period of hospitalisation. Julian did recover from his first psychotic episode, and his hallucinations and delusions decrease considerably with medication. Through family Psycho-education, parents develop understanding of this condition and of the requirement of a “low-key” approach to interacting with the boy as he recovered.

However some obstacles were encountered in Julian’s recovery, since he disliked the side effects of the medication, especially the weight gain and reduced sexual drive/function, and so had poor medication adherence – depression also manifested during the remission, when Julian came to realise about the many losses that followed his condition. He was unable to pursue his university studies and thus, could not continue the law career he had dreamed of. He also experienced difficulties in maintaining friendships or to commit to engaging on a regular basis in physical exercises or sports. When his mood was low, Julian would smoke some cannabis to lift his spirits.

The mother found it very difficult to accept the diagnosis of Schizophrenia and continued to hold the belief that his psychotic symptoms were linked to some spiritual or mystical explanation. She even sometimes declared that she thought of her son not as an ill young man, but a gifted seer or a “chosen one” [based on no rational explanation or series of events], and often engaged Julian in intense, distressing conversations about these issues. In the years that followed his initial assessment, poor medication adherence, ongoing cannabis use [which the patient could not tolerate unlike some other users] and exposure to high levels of intrusive parental emotions led Julian to relapse more often than might otherwise have been the case.


Clinical Features of Schizophrenia

A range of clinical features have been identified and associated with Schizophrenia though research and clinical observations (Mueser & Jeste, 2008). The generally concern the domains of perception, cognition, emotion, behaviour, social adjustment and somatic state.


Perception

At the perceptual level, patients suffering with schizophrenia generally describe a breakdown in perceptual selectivity, with difficulties focusing on essential information or stimuli to the exclusion of accidental details or background noise. Most aspects of the environment seem to be salient, however, the inability to distinguish between figure and ground is a serious problem to the sufferer. During an acute psychotic state, internal stimuli such as verbal thoughts are experienced as auditory hallucinations that have the same sensory quality of the spoken word.

Auditory hallucinations can sometimes be experience as extremely loud thoughts, or as thoughts being repeated by another person aloud (thought echo), as voices speaking inside the head or as voices coming from somewhere in the outer environment. The auditory hallucination may occur as third person making comments on the patient’s action, as a voice speaking in the second person directly to the person, or as two or more people talking or arguing – the effect did may also perceive voices to vary along the number of dementia [may be construed as benign or malevolent, controlling or impotent, or knowing or knowing little about the patient, who may sometimes feel compelled to the demands of the voice or not.

When hallucinations are perceived to be malevolent, controlling, all-knowing, where the individual affected feels compelled to obey the demands of the voice, the situation is deemed to be far more distressing than those who do not have these attributes. While auditory hallucinations are the most common features in schizophrenia, hallucinations may okay other sensory modalities too. Somatic hallucinations also often occur in schizophrenia, with many cases including reports of electricity in the body or the feeling of something crawling underneath the skin [these may be qualified as delusional interpretations. For example, a patient reported that the television was activating a transmitter in her pelvis and she could feel the electricity from this closing insects to grow and move around under the skin. Visual hallucinations [seeing visions] are relatively rare in schizophrenia very common in temporal lobe epilepsy.


Cognition

At the cognitive level, delusions are the most common cognitive clinical feature of schizophrenia, and are false, idiosyncratic, illogical and stubbornly maintained erroneous inferences drawn to explain unusual experiences, such as hallucination. [e.g. patient with auditory hallucinations where an authoritative voice commanding the latter to gather the children, was interpreted by the patient that she had been chosen by God to prepare all the children for the second coming of Christ]

Delusions may also arise from unusual feelings associated with psychosis. Persecutory delusions may develop from feelings of being watched. Delusions of thought insertion or thought withdrawal may develop as explanations for feelings that thoughts are not one’s own, or that one’s thoughts have suddenly disappeared. Factor analyses show that delusions fall into 3 broad categories:

Delusions of influence [including thought withdrawal or insertion, and beliefs about being controlled]; delusions of self-significance [including delusions of grandeur or guilt]; and delusions of persecution (Vahia & Cohen, 2008). Delusions may vary in the degree of conviction with which they are held [great certainty to little servant, the degree to which the person is preoccupied with them [the amount of time spent thinking about the belief], the amount of distress they cause.

Particular sets of the may comprise of a confused sense of self, particularly paranoid delusions with the patient holds the belief that they are being persecuted or punished for misdeeds, or delusions of control where there is a belief that their actions controlled by others [e.g. an unknown source or entity].

A lack of insight along with an impaired judgement is quite common during a psychotic episode. This happens when the patient believes that the contents of their hallucinations and delusions are real, and are incapable of coming to terms with the fact that their experiences and beliefs arise from a clinical condition. However in between psychotic episodes, the patient’s insight may improve and in some cases they may acknowledge that their hallucinations and delusions are symptoms of schizophrenia.

Speech in schizophrenic patients is also fairly hard to understand due to the abnormalities in the underlying thought pattern. This formal thought disorder is characterised by

  1. Tangentiality [answers given to questions are off the point]
  2. Derailment [sentences makes sense but hardly any meaning is conveyed by the sequences of sentences because there is a constant jumping from one topic to another, with very loose association between topics and little logic to what is said]
  3. Incoherence [sentences are incorrectly formed so little sense can be made out of them]
  4. Thought blocking [the patient abruptly stop’s in mid-sentence and is unable to complete the train of thought]
  5. Loss of goal [the difficulty in following a logical train of thought from A to B]
  6. Neologisms [inexistent new words are made up that only have idiosyncratic meaning for the patient]

Cognitive impairment or deterioration occurs in schizophrenia and this may either be general or specific. In cases with general cognitive deterioration, we can observe a reduction in overall IQ with many cognitive function also negatively affected. With specific cognitive impairment one or more of the following functions may be impaired: attention, memory, cognitive flexibility, social cognition and executive function, and most commonly the ability and dedication to follow through on a planned course of action. Cognitive impairment remains a better predictor of disability and vocational functioning than positive symptoms.


Emotions

At the emotional level, especially during the prodromal phase, before an acute psychotic episode, anxiety or depression may occur in response to changes in perceptual selectivity and cognitive inefficiency. One of the main functions of relapse prevention is for patients to learn [and eventually master] the ability to identify and manage prodromal changes in affect.

During psychotic episodes that are intense, anxiety or depression may occur in response to hallucinations, delusions, formal thought disorder and other debilitating symptoms. Inappropriate affect may also be present in hebephrenic schizophrenia, where the patient responds to the internal stimuli such as auditory hallucinations [e.g. laughing wildly] and not the external social context. In chronic cases, blunted or flattened affect can also be observed, and in remission [following an episode of psychosis], the sense of loss [e.g. of valued personal relationships, material, career, etc] that comes with increased insight into the reality of the condition may give rise to post-psychotic depression in some cases.

Behaviour

In terms of behaviour, prodromal excitation may occur prior to an acute psychotic episode, characterised by sleep disturbance, impulsive behaviour, and over-reactivity [may include compulsive behaviour]. Avolition also occurs during psychotic episodes with an observable impairment in goal-directed behaviour.

In some chronic cases, it is common to also find catatonic behaviour along with an impairment in the ability to initiate and organise voluntary movement and posture. Catatonia may be either retarded or excited. Excessive purposeless motor activity is the hallmark of excited catatonia and may include stereotypies [repetitive actions], echolalia [repeating the words said by others] or echopraxia [imitating the actions of others] – these tend to occur without the patient being consciously aware of it [not a conscious choice]. In cases where retarded catatonic behaviour is present there is an observable reduction in purposeful activity; patients may display signs of immobility, mutism, adopt odd postures for extended amounts of time, and display waxy flexibility or negativism.

Social Adjustment

A marked deterioration in social adjustment is also common in schizophrenia, and the ability for self-care, appropriate dressing, grooming and personal hygiene deteriorates – patients with schizophrenia often look dishevelled and unkempt. A decline in also commonly present in the domains of education and work with a withdrawal from regular patterns of socialisation and difficulty making and maintaining significant relationships. A deterioration with others also occurs and schizophrenia tends to have a negative impact on parent-child, marital and sibling relationships.

Somatic State

Approximately 50% of people with Schizophrenia also have comorbid substance use disorders and almost 75% have significant health problems, with the most common one being Chronic Obstructive Pulmonary Disease (COPD) [usually due to heavy smoking]; heart disease and diabetes due to obesity; HIV/AIDS and hepatitis B and C caused by unsafe sex and intravenous drug use [e.g. heroin]. These drug and medical problems in schizophrenia are lifestyle problems. However, one the positive side, schizophrenia is associated with reduced rates of cancer and rheumatoid arthritis (Tandon et al., 2008a).

 

Epidemiology, Course, Outcome and Risk Factors of Schizophrenia

International epidemiological studies that have been reviewed have allowed for a number of conclusions to be deduced regarding schizophrenia. We know that [luckily] under 1% of the population suffer from schizophrenia, and the lifetime risk of the condition is about 0.7% (Saha et al., 2005). More men than women suffer from schizophrenia: the male-female ratio is about 1.4:1 (McGrath et al., 2004). Schizophrenia has an earlier onset in males (20-28 years) than in females (28-32 years) (Murray & Van Os, 1998). The rates for schizophrenia have also been found to be similar across countries and cultures when diagnostic criteria are used (Mueser & Duva, 2011).

Schizophrenia tends to follow a distinctive course although a considerable variability exists across cases (Jablensky, 2009; Jobe & Harrow, 2010; Mueser & Duva, 2011, Tandon et al., 2009). The onset of schizophrenia generally occurs in late adolescence or early adulthood and may be acute or insidious [onset generally takes place over 5 years, starting with negative and depressive symptoms, followed by cognitive and social impairment and finally positive symptoms]. Longitudinal studies suggest that there is an early deterioration phase that extends over 5-10 years, a stabilisation phase and a final gradual improvement phase. In over 50 – 70% of cases, the condition follows a chronic relapsing course, typically with incomplete remission between episodes. However, up to 40% of patients show one or more periods of complete recovery with good adjustment for at least 1 year, and  4 – 20% of cases show complete remission.

Psychotic episodes may last from 1 – 6 months, although some cases extend up to 1 year. They are usually preceded by a prodromal period of a number of weeks. Psychotic episodes may be lessened and the severity of the symptoms ameliorated through early detection and the use of pharmacological and psychological treatment. Inter-episode functioning may differ greatly and better inter-episode functioning is associated with a better prognosis. The duration of remission between episodes may be lengthened through the use of maintenance medication and psychosocial interventions to reduce stress and improve coping and illness management.

With treatment, usually positive symptoms (hallucinations and delusions) abate between episodes but negative symptoms (blunted affect, alogia and avolition) can be enduring and are more likely to persist during remission. In the stabilisation phase of schizophrenia, positive symptoms become less prominent, while negative symptoms and cognitive deficits become more prominent. The lifespan of people with schizophrenia is also 9 years less than that of the general population, and this is partly accounted for by the high rate of suicide during the first 10 years of the disorder and the high rate of comorbid medical disorders that also tend to occur along with schizophrenia. About 50% of schizophrenics attempt suicide or self-harm, and about 10% commit suicide (Heisel, 2008; Schennach-Wolff et al., 2011).

One of the greatest risk factors for schizophrenia is a family history of psychosis. Other risk factors make a small contribution to the overall risk within the context of associated with genetic vulnerability. However until now, it is important to note that we still do not have any clear consensus or evidence on how these risk factors operate and whether environmental factors remain a stronger prediction of the onset of schizophrenia than genetic factors that only set a predisposition [risk] of possibly developing the condition. Prenatal and perinatal risk factors, such as maternal flu infection and obstetric complications, are likely to have a negative effect or indirect effect on the development of the nervous system in line with the neurodevelopmental hypothesis that states how those affected by such issues while also being genetically predisposed to schizophrenia are even more neurologically vulnerable to psychosis (Murray & Lewis, 1987). Trauma exposure and most demographic risk factors (being unmarried, low-SES urban migrant) are associated with higher levels of stress and lower levels of social support [which increases the risk of psychosis in the genetically vulnerable] according to the Diathesis-Stress Conceptualisation of Schizophrenia (Zubin & Spring, 1977).

In the short term, relapse is more likely in cases where these is heavy cannabis use [along with poor personal/subjective tolerance of the effects on consciousness], poor treatment adherence, frequent contact with insignificant extended family members who may display excessive negative emotional expressions towards the patient [e.g. criticism, hostility and emotional over-involvement] and exposure to acute stress life events (Jablensky, 2009).

A poor outcome is associated with substance use and a longer period of untreated psychosis in people who have poor premorbid adjustment and an early insidious onset with no clear stressful life event preceding their first treated episode. One of the main traits associated with a poor outcome is “Anxiety”, and people with this stress profile are generally more sensitive to and reactive to life’s stressful events, along with populations living in a developing economy, and family-based stress associated with excessive negative expressions of emotion. The symptom profile predictive of a poor outcome is also marked by severe negative symptoms, cognitive impairment and lack of depressive symptoms.

A favourable outcome in schizophrenia is associated with a range of factors (Bota et al., 2011). These include good premorbid adjustment, and a brief duration of untreated psychosis characterised by an acute onset in response to precipitating stressful life events. A family history of affective problems/disorders [rather than schizophrenia] or little psychopathology and a personal symptom profile in which there are affective as well as psychotic features are also predictive of a good prognosis. A better outcome tends to follow those who have a favourable life situation to return to following discharge from hospital.

 

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Part 5 of 5 | The Effectiveness of Psychotherapy

 

ClinP_Descr_Header_05

The main help that a psychotherapist provides is psychotherapy, a contractual process where professionals with expert knowledge interact with clients to guide and help them in the resolution of their psychological conflicts, emotional imbalance, psychological problems and address mental health and behavioural difficulties [if any]. Psychotherapy can be offered to both adults and children on an individual, couple, family or group basis.

Often psychotherapists offer therapy as one element of a multimodal programme provided by a multidisciplinary team [e.g. a multidisciplinary adult mental health team may routinely offer a multimodal programme of psychotherapy combined with some mild anti-depressant for depression]. This final section will focus on the evidence base for the overall effectiveness of psychotherapy.


Evidence-based Practice

In today’s trend of mainstream clinical psychology where the mechanical model of early behaviourists has been combined with cognitive psychology to become Cognitive-Behavioural Psychology, there has been a gradual shift from practice guided by descriptions of clinical cases [qualitative, detailed and individual] to “evidence-based” practice guided by the results of empirical studies using the statistical methods of science to make inferences about behaviour [that can be measured at least] on the effectiveness of psychological interventions. This movement has started in part due to the influence of policies derived from the medical field which bases itself on evidence-based medicine [i.e. tested with laboratory-rigour and statistical methodology] (Sackett et al., 1996, 2000).

Evidence practice in medicine as it has been applied to psychology [or should we say behavioural science] involves the judicious and compassionate use of the best available evidence to make decisions about patient or client care. In clinical psychology, this involves considering available scientific evidence about “what works” on one side, and the client’s unique problems, needs, rights and preferences on the other; while also making balanced, compassionate judgements (APA Presidential Task Force on Evidence Based Practice, 2006; Norcross et al., 2006).


Meta-analyses

The most persuasive form of evidence as far as the effectiveness of psychotherapy and other psychological interventions are concerned in regards to empirical measurements and statistical methodology, comes from meta-analyses on controlled trials.

Meta-analysis is a systematic, quantitative approach to reviewing evidence from multiple trials while also reducing the impact of reviewer bias since the data from many trials are synthesised using statistical methods.

In a meta-analysis, effect sizes are calculated for each trial and then averaged across all trials to provide a quantitative index of the effectiveness of a particular form of treatment with a specified population. The effect sizes calculated in meta-analyses express quantitatively the degree to which treated groups improve over untreated control groups [A graphic explanation of the calculation of an effect size in given in FIGURE A.

FIGURE A - EFFECT SIZES

FIGURE A. A Graphic Representation of an Effect Size of 1

 

Table A shows a system for interpreting effect sizes, and using it, it may be seen that .9 is a large effect size, and if such an effect size was obtained in a meta-analysis it would mean that the average treated case fared better than 82% of the cases in the control group. It would also indicate that 71% of cases in the treatment group had a successful outcome compared with 29% of control group cases. Finally, a large effect of .9 would indicate that 17% of the variance in outcome would validly be attributed to the effects of the treatment rather than other factors.

Table A - Interpretation of Effect Size

TABLE A / Note: Adapted from Wampold (2001, p. 53). 1. From Cohen (1988), 2. From Glass (1976). 3. From Rosenthal and Rubin (1982). Binomial effect size display, assuming overall success rate of .5, success rate for treated cases is .5+ correlation with outcome/2, and success rate for untreated cases is .5-correlation with outcome/2. 4. From Rosenthal (1994, p. 239), percentage of variance = d²/(d² +4).

Is Psychotherapy effective? If so, how effective?

Mary Smith and Gene Glass published the first major meta-analysis of psychotherapy result studies in American Psychologist in 1977. They included 375 controlled trials of psychotherapy in their analysis and found an average effect size of .68. They concluded that a typical therapy client was better off that 75% of untreated individuals.

Since that seminal study many meta-analyses have been conducted, and in a synthesis of 68 separate meta-analyses of psychotherapy with children, adolescents and adults with a wide range of different psychological problems, Grissom (1996) found an aggregate effect of .75, indicating that the average treated case fared better than 77% of untreated controls.


Effects of Psychotherapy with Adults

The mentioned meta-analysis conducted by Smith and Glass (1977) also included many studies of therapy with children and young people. In the quest to determining the effects of psychotherapy for adults with psychological problems, Shapiro and Shapiro (1982) conducted a meta-analysis of 143 studies of psychotherapy exclusively involving adult populations. This revealed an effect size of 1.03, meaning that after treatment the average adult who participated in psychotherapy fared better than 84% of untreated control group cases.


Effectiveness of Psychotherapy with Children and Adolescents

The results of 4 broad meta-analyses of studies involving children and adolescents under 18 years with a diverse range of psychological problems receiving a variety of forms of psychotherapy provide evidence for the overall effectiveness of psychotherapy with children (Casey & Berman, 1985; Kazdin et al., 1990; Weisz et al., 1987, 1995). These meta-analyses included more than 350 treatment outcome studies. Effect sizes ranged from .71 to .88, with a mean effect size of .77. This indicates that the average treated case fared better than 78% of control group cases.


Psychodynamic Psychotherapy

Within the psychodynamic tradition, a distinction is made between short-term psychodynamic psychotherapy and intensive long-term psychoanalysis. Short-term psychodynamic psychotherapy involve weekly sessions for periods of 6 – 12 months, while Long-term psychoanalysis involves two or more sessions per week, usually lasting for periods longer than 1 year [Jacques Lacan, one of the main psychoanalytic figures in France, broke from other associations to create his own school where he advocated short psychoanalytic sessions that varied ranging from 10 minutes to more, as he argued that the point of therapy is to shape the patient’s consciousness and depending on the person, this can be achieved by a range of ways, e.g. metaphors or word plays that allows the patient to peer into his own psyche and understand himself]

Two important broad meta-analyses have been conducted to evaluate the effectiveness of psychodynamic psychotherapy with adult mental health problems (Leichsenring et al., 2004; Leichsenring & Rabung, 2011). In a meta-analysis of 17 studies, Leichsenring et al. (2004) found that short-term psychodynamic psychotherapy yielded an effect size of .7 for psychiatric symptoms in patients mainly diagnosed with anxiety and mood disorders when therapy was compared with waiting list or minimal intervention control groups. This indicates that after treatment the average treated case fared better than 76% of controls. In this meta-analysis, the outcome for psychodynamic psychotherapy did not differ from that of other forms of psychotherapy in the 14 studies where such comparisons were made.

In a further meta-analysis of 10 studies, Leichsenring and Rabung (2011) found that Long-term psychodynamic psychotherapy involving more than 50 sessions over periods longer than a year yielded an effect size of .54 for overall effectiveness for complex cases with severe symptomatology, comorbid diagnoses, or personality disorders, when long-term psychodynamic psychotherapy was compared with a range of other therapies including Cognitive-Behavioural Therapy (CBT), dialectical behaviour therapy, family therapy and short-term psychodynamic psychotherapy. This indicates that after treatment the average case fared better than 70% of cases treated with other therapies. The gains made during treatment were sustained at 1 to 8 years after follow up.

The results of these two meta-analyses show that short-term psychodynamic psychotherapy is an effective as other widely used forms of psychotherapy, including Cognitive-Behavioural Therapy (CBT), for common psychological problems such as anxiety and depression in adults; and that long-term psychodynamic psychotherapy is more effective that some other forms of therapy for adults with complex mental health difficulties.


Client-centred Humanistic Psychotherapy

Elliot et al., (2004) conducted a meta-analysis of trials of psychotherapy that fall broadly within the client-centred humanistic psychotherapy tradition [over 90 trials of client-centred, experiential, gestalt and emotionally-focussed therapy were included in the analysis]. Clients in these studies had a wide variety of psychological problems including anxiety, mood, eating and relationship distress. The average duration of treatment was 22 sessions, reflecting about 6 months of therapy. An effect size of .78 was obtained, indicating that the average treated case fared better than 78% of cases in control groups. These results indicate that client-centred humanistic psychotherapy is an effective form of treatment for a range of common psychological problems in adulthood.


Overall Effects of Psychotherapy

FIGURE B summarises the results of meta-analyses, described above, of the effectiveness of psychotherapy from a range of different traditions with adults and children. In this figure, where appropriate, effect sizes from multiple meta-analyses have been averaged, and graphed as success rates based on the system given in TABLE A.

From FIGURE B it can be deduced that meta-analyses of psychotherapy trials yield moderate to large effect sizes that range from .65 to 1.02. When expressed as success rates, the results of meta-analyses indicate that 65 – 72% of people with psychological problems benefit from psychotherapy. Thus approximately two-thirds to three-quarters of people who engage in psychotherapy find that it leads to improvements in their mental health.

figure b - sucess rates w adults & children

FIGURE B. Success Rates of Psychotherapy with adults and children, and Therapy from other schools of thought [traditions] based on Effect Sizes from Meta-analyses

Comparison of the effects of Psychotherapy and Medical Procedures

In order to make sense of the overall effectiveness of psychotherapy, it may be useful to ask ourselves: Are the moderate to large effect sizes associated with psychotherapy very different from those associated with the medical and surgical treatment of physical illnesses, diseases and medical symptoms?

In a synthesis of 91 meta-analyses of various medical and surgical treatments for a range of medical conditions, Caspi (2004) found an average effect size of .5. This falls in the moderate range of effect sizes (.5 – .8) and not very dissimilar to the effect size of .75 from Grissom’s (1996) synthesis of 68 meta-analyses of psychotherapy trials mentioned at the beginning of this section. Hence, it may be concluded with some certainty that the moderate effect sizes associated with psychotherapy are similar to those associated with the treatment of medical conditions.


Deterioration and Drop-Out

A consistent finding within psychotherapy research literature is that up to 10% of clients deteriorate following treatment (Lambert and Ogles, 2004; Lilienfeld, 2007). In a review of 46 studies on negative outcome in adult psychotherapy, Mohr (1995) found that deterioration was associated with particular client and therapist characteristics and particular features of psychotherapy. Deterioration was much more common among clients with obsessive compulsive disorder or severe interpersonal difficulties. Lack of motivation and the expectation of benefiting from psychotherapy without personal effort were also associated with deterioration. Deterioration was more common when unskilled therapists lacked the empathy and did not collaborate with clients in pursuing their agreed goals. Failure to manage counter transference appropriately and frequent transference interpretations were also associated with deterioration.

Dropping out of psychotherapy is a relatively common event. In a meta-analysis of 125 studies, Wierzbicki and Pekarik (1993) found a mean dropout rate of 47%. Dropout rates were higher for minority ethnic groups, less educated clients, and those with lower incomes. Thus, we can conclude that about 1 in 10 clients deteriorate following therapy and that marginalised clients with particularly troublesome disorders and negative attitudes to psychotherapy are vulnerable to dropping out of psychotherapy and deterioration.


Medical Cost Offset

So, all the evidence that has been reviewed shows that psychotherapy is effective for a range of problems and populations. However, an important factor regarding the delivery of psychological treatment is the financial implication of it [i.e. the cost to the economy and health services]: How much does it cost to provide such a psychotherapy service? From this financial perspective, two questions would be of interest:

First: Do clients who received psychotherapy use fewer medical services and so incur reduced medical costs? This saving would be referred to as the Medical Cost Offset.

Second: Is the Medical Cost Offset associated with psychotherapy greater than the cost of providing psychotherapy? If so, we would be able to conclude that psychotherapy has a total cost offset.

Findings from meta-analyses and narrative reviews of the cost-offset literature provide explanations on these questions. In a meta-analysis of 91 studies conducted between 1967 and 1997, Chiles et al. (1999) found that psychotherapy and psychological interventions led to significant medical cost offsets. Participants in reviewed studies included surgery inpatients, high health-service users, and people with psychological and substance use disorders who received psychotherapy or psychological interventions alone or as part of a multimodal programme. Chiles and his team found that medical cost offsets occurred in 90% of studies and ranged from 20% to 30%. In 93% of studies where data were provided, cost offsets exceeded the cost of providing psychotherapy. Greater costs offsets occurred for older inpatient who required surgery, oncology, and cardiac rehabilitation than for outpatients who required care for minor injuries and illnesses. Structured psychological interventions, tailored to patient needs associated with their medical conditions, led to greater medical cost offsets than traditional psychotherapy.

In a set of meta-analyses from earlier studies involving Blue Cross and Blue Shield US Federal Employees Plan claim files and 58 controlled studies, Mumford et al. (1984) found that 85% of studies medical cost offset for psychotherapy occurred, and this was due to shorter periods of hospitalisation for surgery, cancer, heart disease and diabetes – particularly in patients over the age of 55. In a review of psychological interventions for people with a variety of health-related difficulties, Groth-Marnat and Edkins (1996) found that medical cost offsets occurred when such interventions targeted patients preparing for surgery and patients with difficulty adhering to medical regimens. Medical offset also occurred for smoking cessation programmes, rehabilitation programmes, and programmes for patients with chronic pain disorders, cardiovascular disorders and psychosomatic complaints.

Three other important reviews of medical cost-offset literature, which focussed largely on mental health problems in adults rather than adjustment to physical illness, deserve mention. In a review of 30 studies of psychotherapy for psychological disorders and drug and alcohol abuse, Jones and Vischi (1979) found that medical cost offsets occurred in most cases. In a review of eight cost-effective studies for substance abuse, Morgan and Crane (2010) concluded that family-based treatments can be cost-effective. In a review of 18 studies of psychotherapy for psychological disorders, Gabbard et al. (1997) found that in more than in 80% of studies, medical cost offsets exceeded the cost of providing psychological therapies. Significant cost-offsets occurred for complex problems and in studies of psychoeducational family therapy for schizophrenia and dialectical behaviour therapy for personality disorders this was achieved by reducing the need for inpatient care and improving occupational adjustment.

Estimated direct and indirect costs related to mental health problems across Europe

Besides the impact on people’s well-being, the report estimates the total costs of mental ill-health at over EUR 600 billion – or more than 4% of GDP – across Europe / Source: OECD Library

Prevalence by mental and substance use disorder 2017 - our world in data

Prevalence by Mental and Substance use disorder / Source: OurWorldinData

The table below provides a brief summary of the data which follows on mental health and substance use disorders

The table provides a brief summary of the data which follows on mental health and substance use disorders / Source: OurWorldinData

Therefore, to conclude with all the evidence reviewed here, it is widely accepted today that psychotherapeutic interventions have a significant medical cost offset. Those who participate in psychotherapy use fewer extra medical services at primary, secondary and tertiary levels and are hospitalised less than those who do not receive psychotherapy.

 

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Essay // Clinical Psychology: Controversies that surround modern day mental health practice

MentalHealth

Modern day mental health practice could be defined as the application of the four main schools of thoughts that dominate the field of psychology in the clinical setting, by abiding to strict criteria set out by packaged behavioural sets, diagnostically defined by names and categorised depending on the core nature of their specific characteristics in terms of behaviour, aetiology and epidemiology. While these four [biological, psychodynamic, cognitive-behavioural & systemic] main schools of thought have contributed to the development and ongoing evolution of the field of psychology, they also have downsides when applied to different types of psychological cases, with some being more efficient in treating particular disorders while others being hardly efficient and questionable. Applying and integrating these four schools of thoughts with new intuitive fact-based theories to explain psychological constructs and disorders are leading to major innovations in psychology; however with each field’s limitations controversies over the validity of their interpretations and the efficiency of their applied doctrines remain a constant topic of debate among scholars and clinicians.

One of the main controversies that surround modern day mental health practice is the medicalisation of psychological disorders, a tradition influenced by the field of medicine which contradicts an important founding philosophy of psychology, which was originally initiated to study the “mind”, not the physical characteristics of the brain as an organ. Furthermore, evidence suggests that psychological problems are not caused exclusively by organic factors. In anxiety, depression and/or schizophrenia, people with genetic vulnerability to the development of those psychological disorders only do so when exposed to particular stresses in their environment (Hankin & Abele, 2005). However, on the other side of the argument, evidence has also shown that deficiencies in genetics and neurobiological anatomy are linked to psychological difficulties and disorders, and hence nowadays, integrated approaches are used in a variety of assessments when treating patients affected by psychological disorders.

On the theme of medicalization, the debate over eating disorders has led to one of the major controversies within the field between advocates of the biomedical conceptualisation of eating disorders and the feminist position (Maine & Bunnell, 2010). The former sees an individual woman as a patient with a debilitating disease, in need of a cure to her illness; while the feminist position views eating disorders as a condition that is gender specific with the woman as a victim of socio-cultural pressures generated by a male-dominated society governed by a hedonistic economic reality focused on the pursuit of the thin ideal. There is an important distinction that should be made here for the benefit of patients since the feminist view may not fully comprehend that in the case of obesity and emaciation related to eating-disorders, the patients are at severe risk of medical complications such as growth retardation, osteoporosis, gastrointestinal bleeding, dehydration, electrolyte abnormalities and cardiac arrest [in chronic cases]. The social feminist constructivist perspective may be interpreting eating disorder as an image debate of “Fat” versus “Thin”. This may lead to the normalisation of obesity and destructive eating habits which in turn may result in further medical complications that involve surgical interventions. As for the feminists, it may be ethical to acknowledge that obesity & emaciation associated with eating disorders are major health issues that precede further complications such as diabetes, cancer and high blood pressure; and should not be confused with social stigma regarding image, but seen as a sign of poor-health and lifestyle that require attention and effort in providing patients with the medical and psychological help they need to adjust their patterns of life to a healthy one by adopting a culture synchronised with dietary & nutritional education.

Secondly, the medicalization of anxiety disorders as distinct medical & psychological conditions may seem less favourable to the biological model previously mentioned. A mass market of pharmacological products used in treatment has been favoured for being more convenient and less time consuming. This may lead to patients feeling disempowered and hopeless when being treated as victims of an uncontrollable illnesses requiring pharmacological treatment, while already being in a state of distress, shock, disbelief and/or confusion.

Number of people who take antidepressants

Diazepam (Valium) or other benzodiazepines that are highly addictive have also been prescribed for years to treat anxiety disorders. The long term side effects have been trivialised along with the arrogant act of medicalizing fear and courage (Breggin, 1991). Critics of the medicalization of experiences argue that if patients are helped in understanding that panic attacks develop from the misrepresentation of bodily sensations and hyperventilation, this knowledge along with their own courage may strengthen them to take control of their fear. Research has also shown how patients who are educated in cognitive-behaviour techniques learn to use problem-solving and develop other skills (e.g. social – help them build meaningful lasting relationships while letting go of psychosocial burdens) that they lack to reappraise situations that may formerly have brought distress.

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The tragic death of one of the most talented vocalists on the planet, Chris Cornell, has sent a shock throughout the arts world and reports have revealed that the gifted artist was on Lorazepam [a benzodiazepine medication sold under the name Ativan used in the treatment of anxiety disorders], the substance is known to heighten the risk of suicide in those suffering from depression, while a recent investigation (Bushnell et al., 2017) has also shown no meaningful clinical benefit from the addition of benzodiazepines during treatment initiation.

Global Suicide rate per 100 000 population

Suicide Rates Around the World per 100 000 (2016)

Estimated rate of suicide per 100,000 population in selected countries in 2016. / Source: Statista

To prevent such tragedies from affecting the human race, more emphasis could be placed on « the mind » with clear guidance on the « thinking styles » (cognitive scripts) to adopt in the protection of the individual organism’s own psyche (mind). Simple foundations based on psychological logic should be propagated educationally to help people understand their uniqueness as organisms while protecting their psyche [mind] from the influence/control of external environmental factors that are beyond their control [e.g. biased negativity, uninformed prejudicial comments of meaningless acquaintances, etc]; acknowledging the fact that as long as an individual organism is within the boundaries of the law, he is allowed to live the life of his choice, and external factors would only affect one’s psyche if attention is given to them; and selectively ignoring parts of the environment  is also an acquired skill vital in maintaining sanity, along with the ability to select experiences that are positive & progressive to the organism [while discarding negative ones] in the context and theme of their chosen individual lifestyles.

ChrisCornell

An artist many might consider to be the Fréderic Chopin & the Edouard Manet of Rock, composing with his heart and painting with his voice, enigmatic vocalist Chris Cornell, known for timeless titles such as « What You Are« , « Like A Stone« , « The Last Remaining Light« , « Exploder« , « Be Yourself« , « Getaway Car » & « Dandelion » left a hole in the hearts of millions touched by his work. His tragic death is a reminder that further research is required in understanding the thought structure of artistic individuals whose psychological subjective reality would likely be deeper and more complex compared to the average person – an approach focusing on the « mind » rather than the « behaviour or brain » in the tradition of Sigmund Freud would likely reveal and explain the granularity of their psyche; and whether their suicidal decisions are rooted in full awareness and motivated by a reality they consider to be inadequate for their state of consciousness and IQ; and whether appropriate interventions involving the restructuration of their psychosocial patterns/exposure [to prevent the burden of stress] may be more individualistic & appropriate.

This would also shift the focus to the individual’s mind, courage & abilities to handle the world while maintaining a stable sense of self and resilience; and not turn them into biological organisms that are having their neurochemistry savagely altered by powerful chemical substances that are known to affect individuals differently with dangerous & sometimes fatal outcomes.

PrinciplesOfPsychology

The same would apply to sufferers of post-traumatic stress disorder who would benefit of a non-pharmacological and empowering intervention to manage and take control of recurrent intrusive and distressing memories – it may be useful to study fear, distress and courage as normal psychological processes happening on a dimensional scale on a normal continuum from one individual to another where those on the extreme ends of the scales may be considered for psychological interventions.

Similarly, antidepressant medication used to treat depression remains controversial due to its questionable efficacy and side-effects. The high level of effectiveness of SSRIs reported in academic journals was greatly due to only trials with positive results of antidepressants being published while those where antidepressants were found to be no more effective than placebos being rejected. The effects of TCAs and SSRIs have also been found to be negligible in mild to moderate depression but effective in severe depression in meta-analyses (Fournier et al., 2010). The negative side-effects of antidepressants are known to be risky and dangerous where symptoms such as loss of sexual desire and impotence, weight gain, nausea, sedation or activation, and dizziness are known to be some of the more disturbing ones, with effects varying with types of antidepressants – for depressed pregnant women, health risks may affect their offspring. Dangerous antidepressants such as MAOIs are only prescribed to patients who can follow strict dietary patterns that exclude foods with thyramine (e.g. cheese) to prevent risks of high blood pressure and hypertensive crises. Although meta-analyses suggest benefits may outweigh the risks, an increased risk of suicide has also been noted among patients under 25 (Bridge et al., 2007).

Edouard Manet - Le Suicide

Edouard Manet (1832 – 1883), « Le Suicidé« 

Electroconvulsive therapy has also sparked a major controversy as a primitive, dangerous and non-scientific practice for the brevity of its effect and negative side-effects on memory (Read & Bentall, 2010). A thorough review of studies on the effectiveness of ECT and its side-effects [retrograde and anterograde amnesia] revealed it to be effective for a brief duration in treating severe depression [in cases that are unresponsive to psychological treatment] and questionably only supported by psychiatrists with a vested interest in proving ECT’s effectiveness. ECT has also been associated with a slight but significant risk of death, and a qualitative study of patients’ negative experiences concluded that for some ECT leads to fear, shame and humiliation, and reinforces experiences of worthlessness and helplessness associated with depression.

brainbuilding

Medicalization has also led to controversy over the diagnosis of schizophrenia, a condition classified as a disease by the World Health Organization and ranked second only to cardiovascular diseases in terms of overall disease burden internationally (Murray & Lopez, 1996). Diagnosis is believed to be part of best practice in the patient’s “best” interest, however a strongly presented viewpoint by Thomas Szasz (2010) qualified diagnosis as an act of oppression as it may pave way for involuntary hospitalisation; where a deviant, maladjusted or poorly educated person may be subjected to « control » processes that they are not fully aware of – this has been proposed as a « possible » explanation for the greater rates of schizophrenia among ethnic minorities (particularly Africans in the US & those of low-SES groups). This view has also been supported by many who argue that schizophrenia as a distinct category may not be a fully valid diagnostic, but a fabrication constructed that may stigmatise disadvantaged or poorly educated people – while this may be positive in shaping « unacceptable behaviour » and protect citizens & society, some people with moderate symptoms may also be forcefully hospitalised. Thus, nowadays, schizophrenia is not a single definite disorder anymore, but one among others, as it has been revised and turned into a spectrum, known as the schizoid spectrum [with other related disorders]. In the treatment of schizophrenia, medicalisation has also led to the evaluation of psychotherapy as a possibly ineffective treatment (Lehman & Steinwachs, 1998). Freud & others in his discipline acknowledged the treatment of psychosis as problematic with psychotherapy as psychotic individuals tend not to develop transference [interpretation of their hidden feelings, defences & anxiety] to the analyst – unlike neurotic patients. For personality disorders, addictions and other severe mental health problems medicalisation has led to the development of alternative methods of treatment that unlike the traditional authoritarian & hierarchically organised inpatient mental health settings, are run in a more democratic line where service users are encouraged to take an active role in their rehabilitation rather than simply being passive recipients of treatment.

clinicalpsychology

Therapeutic communities have turned out to be effective in the long-term treatment of difficult patients with severe personality disorders with the outcome being more positive with longer treatments. These therapeutic communities are believed to lead to improvements in mental health and interpersonal functioning. For drug misuse issues, the assumption that clinicians make over users attempt to quit being due to conscious guidance & coherent plans should be revised as no evidence suggests so, and more evidence argue that unconscious processes, classical and operant conditioning, erratic impulses, and highly specific environmental cues affect the development and cessation of drug use (West, 2006). According to West, interventions should not stimulate adolescents to think of what ‘stage’ they are in or be matched to a stage, but maximum tolerable pressure should be put on the young person to cease drug use – which contradicts the stages of change model (DiClemente, 2003; Prochaska et al., 1992) where 30 days are allocated to stages [pre-contemplation, contemplation, action & maintenance] based on no evidence. While concepts such as harm reduction programmes with needle exchange, safe injection sites, and the provisions of free tests of quality of MDMA sold at raves remain controversial, some believe they prevent mortality and morbidity (Marlatt & Witkiewitz, 2010), while others argue they send the message that hard drug use [such as heroin] may be acceptable.

The second major controversy in modern day mental health practice remains the “Person or Context” debate where many in the field still question the validity of focusing on context as it shifts attention from the individualistic characteristics of the patient, and whether the focus should shift depending on the disorder and the patient’s age. For example in the treatment of childhood disorders, if difficulties are assumed to be individual ‘psychiatric’ illnesses the risk of focus being solely on the child and not on broader social environment may lead to medical treatments and individual therapy without addressing important risk factors for those of such young age who are influenced by their social environment, e.g. teacher, school and wider social context. This may not be the case for some adults who value a sense of autonomy more than being influenced by wider social contexts that they have no connection to, interest in or affinity for. In contrast, to the autonomic adult, treatment cases of other childhood behaviour disorders such as oppositional defiant disorder and conduct disorders may be particularly problematic, since the major risk factors that should be addressed are social: through interventions such as parent training, family therapy, multisystemic therapy and treatment foster care. For ADHD, the bold emphasis on medication is dangerous as the effects are limited to only 3 years (Swanson & Volkow, 2009), while growth and cardiovascular functioning may be affected that may lead to somatic complaints such as loss of appetite, headaches, insomnia and tics, which are present in 5-12% of cases (Breggin, 2001; Paykina et al., 2007; Rapport & Moffitt, 2002).

Another interesting argument comes from the Scottish psychiatrist and psychoanalyst R. D. Laing (2009) in the 1960s and 1970s who opposed the view that schizophrenia was a genetically based medical condition requiring treatment with antipsychotic medication. His dimensional approach led him to view schizophrenia as a ‘sane reaction to an insane situation’ where the contents of psychotic symptoms were simply viewed as psychological responses to complex, confusing, conflicting and powerful parental injunctions that left no scope for more rational and adaptive modes of expression. Thus, Laing proposed that the treatment involved creating a context where insight into the complex family process [e.g. poor housing, low SES, deviant parents with drug problems, over-involved family members who maintain the patient’s stress, alcohol problems, sexual deviance, incest, lack of financial stability, poor educational motivation, poor emotional education, lack of problem solving skills, lack of sophistication, poor nutrition, restricted finances, etc] of patients with schizophrenia and psychotic response to these could be facilitated. The context here seems partially important in the case where the patient’s delusions and hallucinations are linked, where their interpretation would be the client’s response to conflicting parental injunctions. The experience of psychosis and recovery was a process where the individual could emerge stronger with new and valuable insights regarding the solutions to their problems. However, this has not been supported by any evidence or subsequent research. In contrast, strong scientific evidence points to the importance of a more client-centred individual approach focussed solely on the patient with defective inherited neurobiological factors as major focus for the role they play in schizophrenia, and antipsychotic medication for the reduction of symptoms in two-thirds of psychotic patients affected (Ritsner & Gottesman, 2011; Tandon et al., 2010). Research has supported the hypothesis that suggests the family does affect the psychotic process and that psychotherapy has a place in the management of psychosis, for example personal trauma, including child abuse increases the risk of psychosis, and stressful life events including those within the family can precipitate an episode of psychosis, and high levels of family criticism, hostility and emotional over-involvement increase the risk of relapse (Bebbington & Kuipers, 2008; Hooley, 2007; Shelvin et al., 2008). So for those with a strong sense of family, and heavily involved peers, family therapy delays relapse in troubled families characterized by « extreme » levels of expressed emotion; and cognitive behaviour therapy which stresses the idea that psychotic symptoms are understandable and on a continuum with normal experience can help patients control these psychotic symptoms (Tandon et al., 2010), with solutions to rebuild their lives, their own identity and manage their social circle intelligently by differentiating types of relationship and expectations.

personality

The third and last controversy to be addressed is the ongoing debate in clinical psychology over the categorisation of psychological disorders where many have been arguing over a dimensional outlook on psychological conditions that offers more precision in diagnosis along with a more scientific approach. In the case of childhood behaviour disorders with regard to scientific approaches, there is an ongoing debate over whether they should be viewed and classified in categorical or dimensional terms. While DSM are based on rigid categories, most empirical studies support the view of a dimensional outlook. Furthermore, factor analytic studies consistently show that common childhood difficulties belong to two dimensions of internalizing and externalizing behaviour, which are normally distributed within the population (Achenbach, 2009). Young children diagnosed with oppositional defiant disorder (ODD), conduct disorder and ADHD are part of a subgroup of cases with extreme externalizing behavioural problems, while those with anxiety or depressive disorders have extreme internalizing behaviour problems (Carr, 2006a). By the same dimensional approach, children diagnosed with intellectual disability fall at the lower end of the continuum of intelligence, a trait also normally distributed within the population (Carr et al., 2007). The dimensional approach is not only more scientific, but also has a less stigmatizing and rational approach to human uniqueness. The dimensional approach has also enhanced the movement critical of qualifying psychological deficiencies as ‘real psychiatric illnesses’, conditions such as ADHD, conduct disorder and other DSM diagnoses. Questions have been raised over whether they are invalid fabrications or spurious social constructions (Kutchins & Kirk, 1999). Those who trust the evidence of the dimensionality of childhood disorders argue that they may simply be traits distributed normally among the population where some cases fall on the extreme ends of certain traits, while those who point to the interests of pharmaceutical industries’ financial motives argue that they are spurious social constructions. The latter seems unethical but is a part of the decadent and immoral economic reality that we have allowed to exist. As parents, health and educational professionals, it is clear that the pharmaceutical industry and governments may all gain from conceptualising children’s psychological difficulties as ‘real psychiatric illnesses’. Some schools or uncaring parents may prefer children to receive a diagnosis of ADHD with stimulant therapy as they may have difficulty meeting their needs for intellectual stimulation, nurturance and clear limit-setting; thus these children in their care become more aggressive and disruptive.

In the case of schizophrenia, a dimensional approach has also led to the schizotypy construct as a dimensional alternative to the prevailing categorical conceptualization of schizophrenia (Lenzenweger, 2010). In contrast to the categorical view based on Kraepelin’s (1899) work and used in the DSM which sees schizophrenia as a discrete diagnostic category, this one proposes that anomalous sensory experiences, odd beliefs and disorganized thinking exist in extreme forms of schizophrenia as hallucinations, delusions and thought disorder, but these are simply on continuum with normal experience [i.e. it is present in all ‘normal’ people but peaks in abnormal ones] – a position originally advocated by Bleuler (1911). Research measures have provided support for the dimensional construct of schizotypy (Lenzenweger, 2010) where the continuum may be composed of sub-dimensions; from normal to psychotic experiences. Schizotypy is heritable; and patients with high schizotypy scores but who are not psychotic show attentional, eye-movement and other neuropsychological abnormalities associated with schizophrenia. Further, the dimensional approach has also led to the distinction between schizophrenia and split personality where 40% in the UK equated split or multiple personality with schizophrenia – as popular culture often does. It is clear that schizophrenia does not refer to such characteristics.

dr_jekyll_and_mr_hyde_poster_d'purb

The closest equivalent to split personality is a condition known as dissociative identity disorder (DID), where the central feature is the apparent existence of two or more distinct personalities within the same individual, with only one being evident at a time. Each personality (or alter) is distinct with its own memories, behaviour and interpersonal style. In most cases, the host personality is unaware of the existence of alters and these vary in knowledge of each other. Evidence suggests that the capacity to dissociate is normally distributed within the population and an attribute many use to manage their own lives and network. Those with high degree of this trait may cope by dissociating their consciousness from the experience of trauma (such as child abuse, extreme graphic violence, etc) in early childhood by entering a trance-like state. This dissociative habit is negatively reinforced (strengthened) as an effective distress-reducing coping strategy over repeated traumas in early childhood as it brings relief from distress during trauma exposure. Eventually a sufficient number of experiences become dissociated to constitute a separate personality that may be activated in later life at times of stress or trauma through suggestion in hypnotic psychotherapeutic situations. Treatment often simply involves helping clients integrate the multiple personalities into a single personality and develop non-dissociative strategies for dealing with stress [e.g. argument with work colleagues, new manager, divorce, adolescents leaving home for studies, partner with alcohol problems, over-involved family members, etc] – this helps them deal with tough situations by facing them with problem-solving abilities and skills to come out with a firm resolution and have their views understood. Core symptoms of multiple personality disorder are not treated with psychotropic medication unlike schizophrenia but involves psychological education for patients to learn the skill of mentalizing [understand their own state of mind and that of others].

whoareyou

Finally, with personality disorders, the dimensional approach has led to the trait theory in conceptualizing important aspects of behaviour and experience from a limited number of dimensions. Any given trait is believed to be normally distributed in the population, for example, introversion – extraversion, most people show a moderate level of the trait, however those who exhibit extremely low or high levels [extremes] would have the sort of difficulties attributed in the DSM. So, normal people only differ from the abnormal in the degree to which they show particular traits. The trait theory has become dominated by the five-factor theory (McCrae & Costa, 2008) in recent years. This model includes the dimensions: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. There is evidence for the heritability of all of factors within the Five Factor Model except agreeableness which seems to be predominantly determined by one’s environment (Costa & Widiger, 1994). Thomas Widiger has proposed that the five-factor model may be used as an alternative system for describing personality disorders (Widiger & Mullins-Sweatt, 2010). Widiger also argues that trait theory offers a more scientifically useful approach to assessment with good psychometric properties embraced by its questionnaires (De Raad & Perugini, 2002) – they are reliable and valid, and have population norms. Compared to categorical classification systems, trait models offer a more parsimonious way of describing patients with rigid dysfunctional behaviour patterns which in turn offers a more parsimonious way to conceptualize the development of effective treatments.

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Photo: The Promise of Dawn (J.Hawkes)

The major controversies in modern day mental health practice seem to revolve around the precision and the validity of constructs as psychological illnesses, and since they may stigmatise those who suffer from them, the constant research into better and more modern interpretations and explanations of their characteristics and treatment seem bound to revolutionise the field of psychology, as the movement takes a more dimensional approach; with a new generation of psychologists applying the rules with an open mind and a creative outlook on new perspectives and methods – the field of psychology looks set on a positively progressive course.

UneNation

« A great aggregation of men sane in mind & warm in the heart, creates a moral conscience that is known as a nation » – Ernest Renan / Source: Université Paris 1 Panthéon-Sorbonne

Arthur Hughes - A Music Party 1864

Arthur Hughes (1832 – 1915), « A Music Party« 

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Mis à jour le Mercredi, 26 Juin 2019 | Danny J. D’Purb | DPURB.com

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