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Sociotropy
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Sociotropy is a personality trait characterized by excessive investment in interpersonal relationships and usually studied in the field of social psychology.
People with sociotropy tend to have a strong need for social acceptance, which causes them to be overly nurturant towards people who they do not have close relationships with. Sociotropy can be seen as the opposite of autonomy, because those with sociotropy are concerned with interpersonal relationships, whereas those with autonomy are more concerned with independence and do not care so much for others. Sociotropy has been correlated with feminine sex-role orientation in many research experiments.
Sociotropy is notable in that it interacts with interpersonal stress or traumatic experience to influence subsequent depression.
Sociotropy-Autonomy Scale
The Sociotropy-Autonomy Scale (SAS) was introduced by Aaron T. Beck as a means of assessing two cognitive-personality constructs hypothesized as risk factors in depression. The scale focuses on the two personality traits of Sociotropy (social dependency) and Autonomy (satisfying independency). The development of the SAS was gathered through patient self-reports and patient records collected from therapists. Using psychometrics, from the sample of 378 psychiatric patients questions were placed into a two-factor structure where the final pool of items was 60-109. From there each 30 items generated three factors for sociotropy: Concern About Disapproval, Attachment/Concern About Separation, and Pleasing Others; and three for autonomy: Individualistic or Autonomous Achievement, Mobility/Freedom from Control of Others, and Preference for Solitude. The SAS has 60 items rated on a 5-point scale (ranging from 0 to 4). Scores are then totaled separately on each dimension. The scale has been modified since its development. The current SAS decomposes Sociotropy into two factors (neediness and connectedness). Neediness is associated with the symptoms of depression—and connectedness is a sensitivity towards others, and associated with valuing relationships.
Since the development of the SAS, many other measures of personality constructs have been developed to assess other personality traits with some overlapping with the SAS, but examining for different traits.
Self-control
Sociotropic individuals react differently when faced with situations that involve self-control. Sociotropic individuals consume more food, or try to match a peer's eating habits when they believe doing so makes the peer more comfortable. This is often hypothesized as being a result of the individual attempting to achieve social approval and avoid social rejection. The social pressure and dependence can cause a loss of self-control in an individual, especially if they are unaware of their desire for social acceptance.
Depression
Much research on Sociotropy focuses on links between personality and the risk for depression. People who are very dependent are classified as sociotropic individuals, and are more prone to depression as they seek to sustain their low self-esteem by establishing secure interpersonal relationships. Sociotropic individuals are heavily invested into their relationships with other people and have higher desires for acceptance, support, understanding, and guidance—which is problematic when relationships fail. People who are sociotropic and going through failed relationships are likely to become depressed due to intensified feelings of abandonment and loss. Researchers have a hard time figuring out exactly how much personality affects risk for depression, as it is hard to isolate traits for research, though they conclude that a person can either be sociotropic or independent, but not both.
Research
Sociotropy has been linked to other personality traits such as introversion and lack of assertion. Lack of assertion has been hypothesized to be due to the need to please others to build interpersonal relationships. Individuals who are sociotropic avoid confrontation to prevent abandonment.
Along the lines of lack of assertion there has also been research studying the connection between sociotropy and shyness. The characteristic interpersonal dependence and fear of social rejection are also attributes of shyness. Research shows that many items from the SAS relate to dimensions of dependence and preoccupations for receiving approval of others, which is problematic in interpersonal relationships for people who are shy. Individuals who are shy and sociotropic have internal conflicts to want to avoid others as well as having strong motives to approach people. The results from such research concludes that sociotropy predicts other symptoms of discomfort in assertive situations and in conversations.
Research on the subject also seems to connect a link between higher levels of anxiety and sociotropy. Putting excessive amounts of energy into dependent relationships increases anxiety. The behavioral disposition that causes an individual to depend on others for personal satisfaction can also have an effect on their anxiety levels. The research concluded that anxiety and sociotropy are positively correlated in many situations such as social evaluation, physical danger, and ambiguous situations. Sociotropy and anxiety are present in these situations because they are social by definition, and therefore associated with emphasis on social relationships that are characteristic of sociotropic individuals.
External links
The Sociotropy-Autonomy Scale (SAS)
National Library of Medicine entry
WILEY Interscience Sociotropy-autonomy and interpersonal problems
References
Personality
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Improving Access to Psychological Therapies
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Improving Access to Psychological Therapies (IAPT), also known as NHS Talking Therapies, for anxiety and depression, is a National Health Service initiative to provide more psychotherapy to the general population in England. It was developed and introduced by the Labour Party as a result of economic evaluations by Professor Lord Richard Layard, based on new therapy guidelines from the National Institute for Health and Care Excellence as promoted by clinical psychologist David M. Clark.
Aims
The aim of the project is to increase the provision of evidence-based treatments for common mental health conditions such as anxiety and depression by primary care organisations. This includes workforce planning to adequately train the mental health professionals required. This would be based on a 'stepped care' or triage model where 'low intensity' interventions or self-help would be provided to most people in the first instance and 'high intensity' interventions for more serious or complex conditions. Outcomes would be assessed by standardised questionnaires, where sufficiently high initial scores (a 'case') and sufficiently low scores immediately after treatment (below 'caseness'), would be classed as 'moving to recovery'.
The NICE therapy guidelines presume reliable diagnosis. IAPT therapists do not make formal diagnoses. This calls into question IAPT's claimed fidelity to the NICE guidelines, particularly as it does not monitor therapists treatment adherence.
Evaluation
Initial demonstration sites reported outcomes in line with predictions in terms of the number of people treated (especially with 'low intensity' interventions such as 'guided self-help') and the percentages classified as recovered and as in more employment (a small minority) to ten months later. It was noted that the literature indicates a substantial proportion of patients would recover anyway with the passage of time or with a placebo – in fact the majority of those whose condition had lasted for less than six months, but only a small minority of those whose condition had been longer-lasting.
There has been some debate over whether IAPT's roll-out may result initially in low quality therapy being offered by poorly trained practitioners.
Beacon UK benchmarked IAPT performance across England for 2011–12 and reported that 533,550 people accessed (were referred to) IAPT services – 8.7% of people suffering from anxiety and depression disorders – with around 60% entering treatment sessions. Most local IAPT services did not reach the target of a 50% 'recovery' rate.
In 2012–2013, 761,848 people were referred to IAPT services. 49% went into treatment (the rest either assessed as unsuitable for IAPT or declined), although around half of those dropped out before completing at least two sessions. Of the remainder, 127,060 people had pre-treatment and post-treatment mental health questionnaires submitted indicating 'recovery' – a headline rate of 43%. A report by the University of Chester indicated that sessions were costing three times more to fund than the original Department of Health estimates.
For 2014-15 there were nearly 1.3 million referrals to IAPT, of which 815,665 entered treatment. Of those, 37% completed sufficient sessions, with 180,300 showing a 'reliable recovery' (on anxiety and depression questionnaires completed before and immediately after treatment) – which was just over one in five of those who entered treatment, just under half of those who completed enough sessions. Opinion on IAPT remained divided. The number of trained IAPT therapists did not appear to have met the government's target of 6000, resulting in high caseloads. Some complained of seeing more 'revolving door' patients and excess complexity of cases, while the NHS has acknowledged problems with waiting times and recovery rates. However Norman Lamb, who championed IAPT within the coalition government 2010-2015, disagreed with picking faults with such an extensive and world-leading advance in evidence-based treatment. Others lauded the success in rising numbers of referrals, but warned of the failure to improve recovery rates. It was noted that both antidepressant prescribing and psychiatric disability claims have continued to rise.
In 2017 fewer than half of the Clinical Commissioning Groups met the target (15.8%) for the number of people who should be accessing talking therapies.
There has been no publicly funded independent audit of IAPT . A study of 90 IAPT cases25 https://doi.org/10.1177/1359105318755264, [Scott (2018) IAPT - The Need for Radical Reform, Journal of Health Psychology, ] assessed with a 'gold standard' diagnostic interview revealed that only some recovered, in the sense of losing their diagnostic status. The results were identical whether or not the person was treated before or after personal injury litigation. Similarly, the use of the PHQ-9 in calculating recovery rates for treatment targets has been questioned considering the difficulty a significant minority of the population may have in understanding its content.
In July 2021 55,703 appointments out of the total 434,000 which went ahead involved one or more practitioners who did not have an accredited IAPT qualification. There are about 2000 psychological wellbeing practitioners in the service, with another 1,200 trainees. They are supported by high intensity therapists and counsellors of which there are about 4,000 with 700 trainees.
In 2022 less than 40% of people referred to IAPT services in some areas actually attended their initial assessment and first treatment sessions. Only 57% of people who attended for assessment went on to attend the first treatment appointment. People who self-referred were three times more likely to attend the assessment appointment than those who were referred by their GP.
Updates
In December 2010, Paul Burstow, Minister for Care Services, announced an extension to the IAPT project to include Children and Young Peoples services. The government pledged £118m annually from 2015 to 2019 to increase access to psychological therapies services to children and young people.
When the programme officially started in 2008 it was only for working age adults, but in 2010 it was opened to all ages.
In 2015 Clark and fellow clinical psychologist Peter Fonagy, writing in response to wide-ranging criticism from child and adolescent psychiatrist Sami Timimi, stated that IAPT now has increasing support for the non-CBT modalities recommended by NICE for depression: counselling, couples therapy, interpersonal psychotherapy and brief psychodynamic therapy; and for Children and Young People (CYP-IAPT) more systemic family therapy, interpersonal therapy and parenting therapy is on the way. Timimi described the changes as still "light" on relational/collaborative therapy compared to the 'technical model' derived from 'eminence-based' NICE guidelines via inadequate diagnostic categories.
CYP-IAPT, an application of IAPT model for children and adolescents, was a government-supported initiative in the 2010s. Like its adult IAPT counterpart, CYP-IAPT aimed to improve the availability of, and access to, evidence-based psychological therapies. Unlike its adult counterpart, CYP-IAPT did not involve the recruitment and development of new types of workers; instead, it championed the training of existing staff in evidence-based therapies such as cognitive-behavioural therapy, parenting and interpersonal therapy.
A Payment by Results system is being developed for IAPT, whereby each local Clinical Commissioning Group can reward each local provider according to various targets met for the service and for each client – particularly for how much change in scores on the self-report questionnaires.
The March 2021 issue of the British Journal of Clinical Psychology has highlighted the considerable controversy over IAPT's claims of success, Scott( 2021)26 https://dx.doi.org/10.1111%2Fbjc.12264 and Kellett et al., (2021)27 have responded with their own commentary ‘The costs and benefits of practice-based evidence: Correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’
History
Richard Layard, a labour economist at the London School of Economics, had become influential in New Labour party politics and was appointed to the House of Lords in 2000. He had a particular interest in the happiness of populations and mental health; his father, John Layard, was an anthropologist who had survived suicidal depression and retrained as a Jungian psychologist after undergoing psychoanalysis by Carl Jung. In 2003 Richard Layard met the clinical psychologist David M. Clark, a leading figure in Cognitive Behavioral Therapy who was running the Centre for Anxiety Disorders and Trauma (with Anke Ehlers and Paul Salkovskis) at the Institute of Psychiatry and Maudsley Hospital. Clark professed to high rates of improvement from CBT but low availability of the therapy despite NICE guidelines now recommending it for several mental disorders.
Layard, with Clark's help, set about campaigning for a new national service for NICE-recommended treatments, particularly CBT. One key argument was that it would be cost-effective and indeed eventually pay for itself by increasing productivity and reducing state benefits such as Disability Living Allowance and Incapacity Benefit (which had seen rising claims since their introduction by John Major's Conservative Party in 1992 and 1995 respectively). The plan was accepted in principle by the newly re-elected Labour government in 2005 and gradually put into practice directed by Clark. Layard names several others as having helped gain the initial political traction for the initiative – MP Ed Miliband, psychiatrist Louis Appleby (then National Director for Mental Health), David Halpern (psychologist), psychiatrist David Nutt, MP Alan Milburn (married to a psychiatrist) and eventually the PM Gordon Brown.
In 2006 the Mental Health Policy Group at the LSE published 'The Depression Report', commonly referred to as the Layard Report, advocating for the expansion of psychotherapy on the NHS. This facilitated the development of IAPT initiatives, including two demonstration sites (pilot studies) and then training schemes for new types of psychological practitioner. The programme was officially announced in 2007 on World Mental Health Day. Some mental health professionals cast doubt on the claims early on. In the official publication of the British Psychological Society in 2009, experienced clinical psychologists John Marzillier and Professor John Hall strongly criticised IAPT's promoters for glossing over both the data gaps acknowledged in the NICE reports and the complexity of the multiple issues typically affecting people with mental health problems and their ability to sustain employment; they were met with much agreement as well as angry criticism. One researcher cited the UK initiative as the most impressive plan to disseminate stepped-care cognitive behaviour therapy. But the plan appears not to have worked, Davis (2020)28 in the Journal of Evidence Based Mental Health, noted that 73% of IAPT clients receive low intensity therapy first (guided self help, computer assisted CBT or group psychoeducation) but only 4% are transferred to high intensity therapy and the first transition appointment is the least well attended.
See also
Child and Adolescent Mental Health Services
National Mental Health Development Unit
Troubled Families scheme
General:
Mental health in the United Kingdom
References
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Further reading
Common mental health problems: identification and pathways to care NICE guidelines, May 2011
Some perspectives on improving access to psychological therapies (IAPT) Charlotte Thomas, 2013.
The sorry state of NHS provision of psychological therapy. Paul Atkinson, 2014
External links
Mental health in England
Psychotherapy
Cognitive behavioral therapy
Programmes of the Government of the United Kingdom
Child and adolescent psychiatry
Mental health in the United Kingdom
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Morita therapy
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Morita therapy is a therapy developed by Shoma Morita.
The goal of Morita therapy is to have the patient accept life as it is and places an emphasis on letting nature take its course. Morita therapy views feeling emotions as part of the laws of nature.
Morita therapy was originally developed to address shinkeishitsu, an outdated term used in Japan to describe patients who have various types of anxiety. Morita therapy was designed not to completely rid the patient of shinkeishitsu but to lessen the damaging effects.
Morita therapy has been described as cognate to Albert Ellis's rational-emotive therapy. It also has commonalities with existential and cognitive behavioral therapy.
Background
Shoma Morita (1874–1938) was a psychiatrist, researcher, philosopher, and academic department chair at Jikei University School of Medicine in Tokyo. Morita's training in Zen influenced his teachings, though Morita therapy is not a Zen practice.
Philosophy
Morita therapy focuses on cultivating awareness and decentralizing the self. Aspects of mindfulness are contained in knowing what is controllable and what is not controllable, and seeing what is so without attachment to expectations. Feelings are acknowledged even when one does not act on them. The individual can focus on the full scope of the present moment and determine what needs to be done.
Morita therapy seeks to have patients learn to accept fluctuations of thoughts and feelings and ground their behavior in reality. Cure is not defined by the alleviation of discomfort (which the philosophy of this approach opposes), but by taking action in one's life to not be ruled by one's emotional state.
Stages
Morita is a four-stage process of therapy involving:
Absolute bed rest
Occupational therapy (light)
Occupational therapy (heavy)
Complex activities
In the first stage, the patient is ordered to stay on absolute bed rest, even to take meals, only rising to use the restroom. When the patient expresses boredom, they may move to the second stage.
During the second stage, patients are introduced to light and monotonous work that is conducted in silence. The second stage takes three to seven days. Patients may wash their face in the morning and evening, read aloud from the Kojiki, and write in a journal. In this phase, patients are also required to go outside. No strenuous physical work is allowed, such as climbing stairs and sweeping.
In the third stage, patients are allowed to engage in moderate physical work, but not social interaction. This stage lasts from three to seven days. For people with physical injuries, it is the phase where they were treating themselves through physical therapy. The patient is encouraged to spend time in creating art.
The fourth stage is the stage where patients are reintroduced into society. It can last from one to two weeks. The patient integrates meditation and physical activity. The patient may return to the previous stages and their teacher.
Methods (Western)
Shoma Morita's work was first published in Japan in 1928. Morita Therapy Methods (MTM) adapted the therapy to modern western culture. For example, the original Morita treatment process has the patient spend their first week of treatment isolated in a room without any outside stimulation, which has been modified in MTM.
The shinkeishitsu concept has also been broadened to also consider life situations in which modern westerners may find themselves, involving stress, pain and the aftermath of trauma. MTM is also designed to help patients deal with shyness. MTM is also roughly divided into four basic areas of treatment.
Research
A Cochrane review conducted in 2015 assessed the effectiveness of Morita based therapy for anxiety disorder in adults. They defined Morita therapy as any care practice defined as Morita therapy by the carers and involving at least two of the four phases. The review does not include a single case of Classic Morita Therapy being used, all studies were conducted in hospitals in the People's Republic of China between about 1994 and 2007. The review states there is very low evidence available and it is not possible to draw a conclusion based on the included studies.
See also
Shoma Morita
Naikan
Quiet sitting
David K. Reynolds
Buddhism
References
Further reading
Morita, Shoma (1998) (Kondo, Akihisa, trans., LeVine, Peg, ed.) Morita Therapy and the True Nature of Anxiety-Based Disorders. State University of New York Press.
Chang, SC. (1974). Morita Therapy. American Journal of Psychotherapy, 28: 208–221.
Chang, SC. (2010). Psychotherapy and culture. Morita therapy: An illustration. World Cultural Psychiatry Research Review. December, 135–145.
Deng Yuntian, Out of the quagmire of obsessive compulsive disorder 走出強迫症的泥潭. A detailed book about Morita Therapy.
Fujita, Chihiro. (1986). Morita Therapy: A Psychotherapeutic System for Neurosis. Tokyo: Igaku-Shoin.
Ikeda, K. (1971). Morita's theory of neurosis and its application in Japanese psychotherapy. In J.G. Howell (Ed.), Modern Perspectives in World Psychiatry (519-530). New York: Brunner/Mazel.
Ishiyama, Ishu. (1988). Current status of Morita therapy research: An overview of research methods, instruments, and results. International Bulletin of Morita Therapy. (1:2), November, 58–83.
Ives, Christopher. (1992a). The teacher-student relationship in Japanese culture and Morita therapy. International Bulletin of Morita therapy. (5:1 & 2), 10–17.
Kitanishi, Kenji. (2005). The philosophical background of Morita therapy: Its application to therapy. In Asian Culture and Psychotherapy: Implications for East and West. University of Hawai'i Press, p169-185).
Kondo, Akihisa. (1953). Morita therapy: A Japanese therapy for neurosis. The American Journal of Psychoanalysis, (13:1), 31–37.
Kondo, A. (1975). Morita therapy: It's Sociohistorical Context. In Arieti, Silvano and Chrzanowski, Gerard (1975). New Directions in Psychiatry: A Worldview.
Kondo. A. (1983). Illusion and Human Suffering: A brief comparison of Horney's ideas with Buddhistic Understanding of mind. In Katz, Nathan (Ed), Buddhist and Western Psychology. Boulder: Prajna Press.
Kora, Takehisa. (1965). Morita Therapy. International Journal of Psychiatry. (1:4), 611–640.
LeVine, Peg (2017). Classic Morita Therapy: Consciousness, Zen, Justice, Trauma. London: Routledge Press.
LeVine, P. (2016). Classic Morita therapy: Advancing consciousness in psychotherapy. Psychotherapy and Counselling Journal of Australia.
LeVine, Peg (1991). Morita psychotherapy: a theoretical overview for Australian consideration. Australian Psychologist, 26 (2), 103–107.
LeVine, P. (1994). Impressions of Karen Horney's final lectures. Australian Psychologist. (29:1), 153–157.
Ogawa, Brian (2007). A River to Live By: The 12 Life Principles of Morita Therapy, Xlibris/Random House.
Ogawa, B. (2013). Desire For Life: The Practitioner's Introduction to Morita Therapy for the Treatment of Anxiety Disorders. XLibris Publ., Indiana
Psychotherapy by type
Zen
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Competence (polyseme)
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Competence (also called competency or capability) is a polyseme indicating a variety of different notions. In current literature, three notions are most evident. The first notion is that of a general competence, which is someone's capacity or ability to perform effectively on a specified set of behavioral attributes (e.g. performances, skills, attitudes, tasks, roles, talents, and so forth). The second notion refers to someone's capacity or ability to successfully perform a specific behavioral attribute — be it overt or covert — like learning a language, reading a book or playing a musical instrument. In both notions, someone may be qualified as being competent. In a third notion, a competence is the behavioral attribute itself, instead of a general or specific capacity or ability. One may for example excel at the competence of baking, at the competency of ceramics, or at the capability of reflexivity.
The pluralized forms of competence and competency are respectively competences and competencies. According to Boyatzis (2008) competencies are part of a behavioral approach to emotional, social, and cognitive intelligence. Moreover, competence is measurable and can be developed through training. In the context of human resources, practice may enable someone to improve the efficiency or performance of an activity or a job.
Concepts like knowledge, expertise, values or desires are not behavioral attributes but can be contained in behavior once executed. Take for example sharing knowledge or actualizing a desire.
Etymology
The term 'competence' isn't novel and predates literature in the 20th century. It first entered professional literature via the article Motivation reconsidered: The concept of competence authored by R.W. White in 1959. He introduced the term competence to describe those personality characteristics associated with high motivation and superior performance. Postulating a relationship between achieved capacity and competence motivation, White defined competence as an ‘effective interaction (of the individual) with the environment’.
In the late 1960s, the 'Competence movement' had been initiated by David McClelland. The movement has its origins in the conspicuous failure of educational qualifications to predict occupational success. The term gained traction in 1973, when McClelland wrote a seminal paper entitled Testing for Competence Rather Than for Intelligence. McClelland followed White's approach in arguing that capacity is more important than intelligence.
The term has since been popularized, most notably, by individuals such as:
Thomas F. Gilbert, in Human competence: engineering worthy performance (1978);
Richard E. Boyatzis, in The Competent Manager: A Model for Effective Performance (1982);
C. K. Prahalad and Gary Hamel, in The Core Competence of the Corporation (1990) and
Daniel Goleman, in Emotional Intelligence: Why It Can Matter More Than IQ (1995).
Its uses vary widely, which has led to considerable misunderstanding. Studies on competence indicate that competence covers a very complicated and extensive range of disciplines, ranging from human resources to psychology and from science to education, with various scholars holding different interpretations of the term. According to Zemke (1982), the terms 'competency', 'competence', and their affiliated counterparts are akin to "Humpty Dumpty words" that derive their meaning solely from the interpreter's intent. This issue arises not due to ill intentions, ignorance, or commercial motives, but stems from procedural and philosophical variations among those vying to establish and shape the concept. This involves constructing the blueprint for how the broader population will incorporate competencies into their routine training endeavors.
Competence and capability
In an influential paper from 1992, Dorothy A. Leonard took on a knowledge-based approach when discussing competency in the context of managerial and technical systems. She defined a 'core capability' as a set of knowledge that distinguishes a company strategically. Core capability wasn't new concept, back in the '90s. Other scholars have also referred to it using various terms like distinctive competences, core competencies, resource deployments, and invisible assets. Leonard was however the first to explicitly plot core capabilities against core rigidities. In a narrow sense, core rigidities represent inappropriate knowledge-sets that can hinder a firm's progress. Following the release of this paper, a tendency has grown to employ the terms competencies and capabilities interchangeably, often without clear differentiation. In other instances, a more precise definition is given priority over a highly inclusive scope.
Competence and performance
Performance has been described by some scholars as the capacity or ability to accomplish specific tasks. Noteworthy figures such as White, McClelland, and Boyatzis have all upheld the notion that competence is tantamount to effective performance. Furthermore, a consensus has arisen among scholars like McClelland, Boyatzis, Spencer and Spencer, as well as H.F. Evarts, regarding the similarity between competence and superior performance. Authors including McClelland, Kanungo and Misra, and Martin and Staines consider competence to be successful performance. All these conceptualizations corroborate performance's role as a neutral carrier for competence. Oftentimes, the term "performance" is extended to delineate the capacity or ability of mechanical, rather than biological systems, to fulfill certain tasks. This task-oriented approach diverges from a behavioral approach as to evade anthropomorphisms. Amidst ongoing developments in artificial intelligence, mechanistic systems receive anthropomorphic characteristics increasingly often. The way performance is being defined mirrors attempts made by authors to emphasize core competence in a similar light. This attempt has failed however, since a consensus on consistent use of competence and competency as separate terms has not been established.
Competence and intelligence
In his influential paper 'Testing for Competence Rather Than for Intelligence' David McClelland sheds light on the advantages of measuring competence over intelligence. McClelland points out that the traits measured by traditional intelligence tests do not reliably correlate with high-level performance in society. He goes on to identify a significant error in categorizing these abilities as "general intelligence", advocating for a more nuanced approach. McClelland's approach acknowledges the multifaceted nature of human capabilities, signaling a departure from a singular focus on cognitive or intellectual abilities.
McClelland emphasizes that there's no solid evidence to suggest that human traits, including cognitive abilities, are innate and cannot be altered. This perspective aligns with the idea that individuals have the capacity to grow, learn, and develop new skills throughout their lives. McClelland's perspective encourages a move away from the pursuit of pinpointing abstract ability factors. Instead, he urges the adoption of assessments that align with the evolving nature of human potential. He suggests that tests rooted in life-outcome behaviors can validate their worth by demonstrating that a person's ability to perform such tasks improves as their competence in those areas increases.
Competence typologies
Atomistic and holistic competence
In 1996, a paper titled "What is competence?" was published by Hager and Gonczi, which addresses an apparent tension between atomistic and holistic competence. Hager and Gonczi criticize the misconception among scholars that labeling an approach as atomistic automatically warrants its rejection without further justification. They emphasize the necessity of justifying the application of any competence standard. To illustrate their point, they draw an analogy with chemistry, where discrete atoms come together to form molecules with distinct properties. Similarly, in the interpretation of competence, especially occupational competence, the authors assert that breaking down an occupation into isolated tasks, as done in a task-oriented approach, is inherently atomistic. This approach fails to provide a synthesis of the tasks, thereby undermining the complex nature of the occupation and corresponding competences. On the other hand, Hager and Gonczi caution against adhering strictly to a rigid holism that dismisses all forms of analysis. They acknowledge that some degree of atomism in competence approaches may be necessary, as long as it is complemented by an appropriate amount of holism. Finding the right balance between analysis and synthesis is crucial for understanding and developing competency standards effectively.
Occupational competences are constructs, which are often inferred from the performance of complex tasks. In contrast, the performance of a task is directly observable and doesn't have to be inferred. Unlike atomistic tasks, holistic tasks are not discrete and independent. For example, practice and assessment, will typically involve a simultaneity of several tasks. Furthermore, these tasks will involve ‘situational understanding’, which means that a worker must take into account multiple contexts while being involved in practice. Although tasks are given as an example, Hager and Gonczi stress the importance of integrating competence standards as to also include attributes. Forgetting about attributes and concentrating solely on tasks may lead someone to lapse into a narrow view of occupational competence, they insist. Approaches to competence that focus exclusively on either tasks or attributes ignore the complex nature of competence. Hence an integrated approach to competence standards, which integrates key tasks and attributes, is supported.
Behavioral and functional competence
The competence movement has inspired individuals from a variety of countries like the United States, the United Kingdom, France, Germany and Australia. Two traditions in particular have represented the early stages of the competence movement, namely the behavioral (or US) approach and the functional (or UK) approach. Multiple scholars have attempted to differentiate between these two traditions. Delamare Le Deist and Winterton (2005) are convinced that since the 1990's the behavioral conception of competence had been transformed into a broader functional conception, which includes knowledge and skills alongside behavioral characteristics. Terry Hyland (1997) offers an alternative interpretation. According to Hyland, alternative models only purport to include wide-ranging knowledge and values. He supposes that functional analysis, which would be inherent to behavioral approaches, is primarily committed to the assessment and accreditation of performance outcomes, not performance improvement. Those who wish to apply their models to value-laden occupations, such as teaching, run into the problem that competence systems, whether these are atomistic as in the British model or allegedly holistic as in the Australian model, are concerned only with performance outcomes, not with the processes of learning and development. Chivers and Cheetham (2000) supplement that not only does the functional approach favor outcomes over processes, it heavily emphasizes occupational standards over vocational standards. Furthermore, Hyland clarifies that functional analysis can only wish to supplement or temper a behaviorist approach. Hyland hereby firmly presents the key difference between the behavioral and functional approach. Even within the predominantly behavioral approach, many conceptions of competence now include knowledge and skills alongside attitudes, behaviors, work habits, abilities and personal characteristics. The behavioral approach is promoted most notably by David McClelland, Boyatzis, and Spencer and Spencer.
Professional competence
Since the 1950s, the concept of competence has found its way into professional literature, transforming various fields and shaping the way we understand professional capabilities. Over the decades, competence models have played a significant role in mapping professions and crafting effective professional education and development programs. At its core, Mulder (2014) suggests, competence development is a socio-constructivist journey. It thrives on the dynamic interplay of social interactions, wherein professionals engage in context-specific quests to improve their capacity.
There have been numerous competence frameworks supporting competence development. One such initiative is competence-based teacher education (CBTE), which came about during the 1970s. Rooted in behavioristic psychology and educational philosophy, CBTE sought to prepare students for specific functions. However, the undertaken was not devoid of challenges and critiques. In response to the limitations of function-oriented perspectives, the concept of integrated occupationalism emerged. Unlike a narrow focus on job profiles, this approach embraced a broader vision. It emphasized holistic, generic and integrated capabilities that are vital for navigating the complexities of occupational roles. On top of integrated occupationalism, situated professionalism emerged. This theory established a nexus between competence and the context in which professionals interact. At the core lies the cultivation of a professional identity, reflecting the principles of situated cognition. It delves into the idea that competence is shaped by the expectations of stakeholders, guiding the professional towards desired actions and outcomes. The culmination of these endeavors has resulted in the enrichment of professional and practice-based learning across many fields.
Personal competence
In his study, Day (1994) points out that beginning in the 1980s, there has been a growing acknowledgment within both business and education sectors regarding the development of personal profiles and portfolios. As a result, employees are now significantly more involved in identifying their individual learning needs. This has led to the recognition and acceptance of personal development as an integral aspect of professional growth. Furthermore, Day's study indicates that personal competences can be examined separately from one's professional competence, though it might be useful to consider both.
Scholars frequently examine interpersonal and intrapersonal competences. For instance, Park et al. (2017) conducted a study on a tripartite taxonomy of character, investigating interpersonal, intrapersonal, and intellectual competences in children. Park et al. has built upon the competency clusters introduced by the National Research Council (NRC). The tripartite taxonomy was however already apparent since B. B. Rothenberg released her study 'Children's social sensitivity and the relationship to interpersonal competence, intrapersonal comfort, and intellectual level' in 1970.
Park et. al has gathered evidence supporting the usefulness of a tripartite taxonomy of character within the school context. The study defines its taxonomy as follows: interpersonal character includes gratitude, social intelligence, and self-control, while intrapersonal character involves academic performance and perseverance. Lastly, intellectual character includes curiosity and enthusiasm. Based on this research orientation, Park et. al. found that interpersonal competence predicts positive peer relations, intrapersonal competence predicts grades and regulated behavior, and intellectual competence predicts class participation and active learning.
Core competence
Core competence can be interpreted as the competence of an organization, but may also pertain to a group of individuals operating within an organization. Core competences encompass the amassed capabilities within an organization, in particular attempts to harmonize professional skills and technological innovation. At its essence, core competence includes involvement, commitment and communication, transcending organizational boundaries and hierarchies, while fostering a culture of inclusivity within the organization.
At the nexus between 'core competences' and 'end products' are the core products. Core products are the physical components (e.g. subassemblies) that increase the value of the end products. Well-targeted core products allow a company to optimize its development stage and go-to-market strategy. By increasing the number of application arenas for its core products, a company can systematically improve efficiency, and reduce expenses and risks associated with novel product creation. In essence, well-targeted core products have the potential to yield economies of both scale and scope.
Metacompetence
According to Brown (1993), metacompetences refer to advanced capabilities associated with learning, creating, adapting and anticipating, rather than merely showcasing a capability to perform on a specific task. This is particularly evident in learning and reflecting, which are crucial for developing mental frameworks. Metacompetences often encompass the concept of 'learning to learn'. Metacompetence can also be summarized as the capability to improve one's competences.
Other typologies
Various other typologies exist to categorize competence in a wider context. These include:
Social competence: the ability to navigate social interactions effectively.
Cultural competence: the ability to meet cultural expectations.
Cross-cultural competence: the ability to adapt effectively in cross-cultural environments.
Communicative competence: the ability to communicate adequately, both verbally and nonverbally.
Linguistic competence: the mastery of a specific language, including grammar, vocabulary, and pronunciation.
This list is not exhaustive. Competence typologies cover a wide range, with new typologies emerging regularly to address specific contexts.
Disciplines
Education
Growing demand for knowledge acquisition across various professional and personal spheres has raised the importance of effective education. Beginning in the late 1980s, governmental intervention worldwide has led to a considerable reconsideration of competence outcomes at all levels of the educational spectrum, encompassing elementary, secondary, tertiary, vocational, empirical and adult education. The value and valuation of these outcomes serve as criteria for assessing the productivity and quality of the educational system. According to Klieme et. al. (2008), effective education could no longer be supported by a rigid canon of intergenerational knowledge and professional qualifications. A more dynamic approach is needed to meet the everchanging competence requirements.
Academia
Academic competence, seen as a subset of student competence, hinges on the effective application of study skills. According to a study conducted by Gettinger and Seiberts (2002), students across all grade levels who possess strong study skills tend to excel academically. However, they suggest, for study skills to be truly effective in promoting academic competence, students must exhibit enough willingness and motivation to engage in studying. Student engagement and proper utilization of study skills are closely intertwined, both bolstering academic competence. Unfortunately, many students pass through the educational system without attaining the level of academic competence necessary for academic success. In light of this, Gettinger and Seiberts emphasize prioritizing research aimed at implementing effective classroom strategies and promoting effective study habits among all students.
Human resources
Leading up to the 1990s, the application of 'capability' as a behavioral approach (competence) had primarily centered around innovation and learning experiences aimed at fostering capability in both educational and workplace settings, as noted by Stephenson & Weil (1992) and Graves (1993). During the 1990s, in particular in Australia, people grew hesitant of the behavioral approach. The association between capability and human resources strengthened, shifting away the attention from education. Hase & Davis (1999) explains this transgression as follows: while competencies form the foundation of capability, competencies alone may be insufficient for achieving optimal human resource management. They proclaim that competencies are rooted in a traditional 'pedagogical paradigm', which fails to fully equip individuals with the attributes needed to succeed in a workplace setting.
Miscellaneous
Other relevant disciplines, wherein competence plays a role, are among others science, pedagogy, professional psychology, healthcare, and engineering.
See also
References
Human behavior
Human resource management
Incompetence
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Rehabilitation counseling
|
Rehabilitation counseling is focused on helping people who have disabilities achieve their personal, career, and independent living goals through a counseling process.
Rehabilitation Counselors can be found in private practice, in rehabilitation facilities, hospitals, universities, schools, government agencies, insurance companies and other organizations where people are being treated for congenital or acquired disabilities. Over time, with the changes in social work being more psychotherapy-oriented, rehabilitation counselors take on more and more community engagement work, especially as it relates to special populations. Some rehabilitation counselors focus solely on community engagement through vocational services, others in various states qualify as both a certified rehabilitation counselor (CRC) and a licensed professional counselor (LPC), enabling them to focus on psychotherapy.
History
United States
Historically, rehabilitation counselors primarily served working-age adults with disabilities. Today, the need for rehabilitation counseling services extends to persons of all age groups who have disabilities. Rehabilitation counselors also may provide general and specialized counseling to people with disabilities in public human service programs and private practice settings.
Initially, rehabilitation professionals were recruited from a variety of human service disciplines, including public health nursing, social work, and school counseling. Although educational programs began to appear in the 1940s, it was not until the availability of federal funding for rehabilitation counseling programs in 1954 that the profession began to grow and establish its own identity.
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Education and training
Though no specific undergraduate degree is required, the majority of rehabilitation counseling graduate students have undergraduate degrees in rehabilitation services, psychology, sociology, or other human services-related fields. As a master's degree is required at a minimum, rehabilitation counselors are trained at the graduate level, with most earning a master's degree, and a few continuing on to the doctoral level. The Council on Rehabilitation Education (CORE) formerly accredited qualifying rehabilitation counselor education programs, but the Council for Accreditation of Counseling and Related Educational Programs (CACREP) assumed this function in 2017. Not all programs meet accreditation requirements. Graduates of unaccredited programs may experience difficulty applying for state licensure and national certification. Rehabilitation counselors are trained in the following areas:
Individual and group counseling
Medical and psychosocial information
Problems and community engagement of special populations
Evaluation and assessment
Research utilization
Employment and occupational choice
Case and caseload management
Job development and placement
Accredited rehabilitation counselor education programs typically provide 60 credit hours of academic and field-based clinical training. Clinical training consists of at least a semester of practicum and a minimum of 600 hours of supervised internship experience. Clinical field experiences are available in a variety of community, state, federal, and private rehabilitation-related programs.
Professional certification and licensure
The Commission on Rehabilitation Counselor Certification (CRCC) grants certification to counselors who meet educational requirements and have passed an examination indicating that they possess the competency and skill to become a Certified Rehabilitation Counselor, (CRC in the United States; CCRC in Canada). A Master's degree is required to obtain certification. Certification as a rehabilitation counselor is not mandated by any state or federal laws, however eligibility to sit for the certification exam is mandated by federal law for those wishing to work for state/federal vocational rehabilitation systems. Some states have Licensed Rehabilitation Counselors (LRC), which places LRCs at the same level as other licensed social service professionals. In other states the CRC qualifies the rehabilitation counselor to obtain the Licensure as a Professional Counselor (LPC). Certification is highly desirable to many employers.
Social relevancy
Community service to a culturally and ethnically diverse population, professional functions, critical thinking, advocacy, applied research activities, and ethical standards are integrated throughout rehabilitation counselor preparation and development. Though rehabilitation counselors are adept at understanding medical issues surrounding the disability (as proven by certification/licensure), they are trained in the social model of disability, which identifies systemic barriers, negative attitudes and exclusion by society (purposely or inadvertently) that mean society is the main contributory factor in disabling people. Rehabilitation Counselors are often advocates in the community for people with disabilities outside of the workplace, with most doing some form of community engagement. As a good portion of counselors have disabilities themselves, the counseling process often emphasizes self-advocacy skills. Rehabilitation counselors can be found in the leadership of many prominent organizations that support human rights and civil rights for people with disabilities such as American Coalition of Citizens with Disabilities, National Black Deaf Advocates, etc.
Notable rehabilitation counselors
Antonia Darder Aguilo - Public Intellectual, Leavey Presidential Endowed Chair in Ethics and Moral Leadership in the School of Education at Loyola Marymount University
Bill Copeland - Award-winning Poet
Laurence M. Foley - American Diplomat to Jordan
Patricia Gerard - First female Mayor of Largo, FL
Juan de Dios Ramírez Heredia - Spanish Romani politician
Al Jarreau - Grammy-winning Jazz Musician
Young Woo Kang - First Korean man with vision impairment to earn a PhD, Creator of braille alphabet for the Korean language
Robert Kelly - Navy Veteran, Film-inspiration
Kathleen Kenna - Canadian Journalist in Afghanistan
Erin Pac - U.S. Olympic Bobsledder, 2010 Bronze-medal winner
Dianne Primavera - U.S. Legislator for the state of Colorado
Kathleen Hawk Sawyer - Former Director of U.S. Federal Bureau of Prisons
Alberta Banner Turner - First African-American woman to earn a PhD in Psychology from The Ohio State University
Rehabilitation counseling careers
Careers in the profession
In the United States, many rehabilitation counselors work in a variety of arenas. The predominant placement of rehabilitation counselors are state rehabilitation programs as Vocational Counselors, social service agencies as Administrators, and at the collegiate level as Disability Counselors/Specialists:
State rehabilitation programs
The predominant need for rehabilitation counselors is within federal/state funded vocational rehabilitation programs. While the Veterans Benefits Administration has its own vocational rehabilitation program, the rest of Federal/State Vocational Rehabilitation Programs are funded and regulated by the Rehabilitation Services Administration (RSA), a division of the U.S Department of Education. Although policies vary from state to state, rehabilitation counselors who work in the federal/state systems typically must hold a master's degree in rehabilitation counseling, special education or a related field, and are required to be certified or be eligible to sit for the certification examination. People accepting employment in the federal/state Vocational Rehabilitation programs do so with the agreement they will meet these qualifications by a specified date to maintain employment.
Social service agencies and the corporate sector
Rehabilitation Counselors can work in the non-profit/corporate sector in various ways. Though the majority start as counselors, specializing in career counseling, most rehabilitation counselors that work in the non-profit arena rise to the administration level, either in supervising staff or directing programs for people with disabilities. Others supervise staff that work in case management programs that serve people with disabilities. Some rehabilitation counselors work with Independent Living Centers, doing community engagement, advocacy, outside referrals, and social service provision for people with disabilities. Entrepreneurial rehabilitation counselors also work as consultants, establishing their own private service agencies. Counselors in working with corporations focus on community relations or corporate service, serving as liaisons between companies and charities or service programs.
College disability counselors and specialists
By law all community colleges, colleges and universities are required to make reasonable accommodations for students with disabilities. To satisfy this requirement most collegial settings have a Disability Resources Center, a Special Needs Coordinator or a similar office. Staff are responsible for coordinating services that may include but are not limited to: advocacy/liaison, computer access, counseling (academic, personal, vocational), equipment loan, information/referral services, in-service awareness programs, notetakers, on campus orientation and mobility training for visually impaired students, priority registration assistance, readers, scribes, shuttle (on-campus), sign language interpreters, test proctoring/testing accommodations, and tutors.
Some adaptive technological accommodations may include but are not limited to: Adaptive computer technology (including voice activated and speech output), Assistive listening devices, Films/videotapes about disabilities, Kurzweil personal reader, Large print software, Print enlargers (CCTV), Raised-line drawing kit, Tactile map of campus, Talking calculators, Tape recorders/APH Talking Book Machine, TDD for hearing impaired, Wheelchair, Wheelchair access maps.
Students who have documentation proving their disability status and the staff are trained to access or have knowledge of the necessary services according to the students' unique need. As the college level is different from the primary school system, the same services that a student may have received within a special education program in high school may not be required at the collegiate level. A wide variety of students with disabilities can be served, some examples are individuals with: learning disabilities, sensorial disabilities (hearing loss, vision loss, etc.), physical disabilities (cerebral palsy, etc.) and psychological disabilities.
Forensic rehabilitation counselors
Forensic rehabilitation counselors can work as consultants, serving as witnesses and advocates in the legal profession. Forensic rehab counselors serve as legal advisors with specialized information on disability in the areas of higher education access, Social Security, marital dissolution, personal injury, and Worker's Compensation.
According to a survey of 1,220 Certified Rehabilitation Counselors (CRC) conducted by the Commission on Rehabilitation Counselor Certification (CORE), CRCs working within a forensic/expert witness job function have the highest annual salary ($93,000) of all job functions analyzed. Furthermore, when average salaries were analyzed by primary work setting, CRCs working within business or industry have the highest annual salary ($78,000) of all settings listed, which is $30,000 more than CRCs working in state/federal rehabilitation agencies. High annual salaries in the forensic area may be a key attraction for CRCs seeking to transition from the public sector. Academic programs require a graduate degree from an accredited rehabilitation counseling program, and enable the student to: learn about the role that counselors provide within the legal system; gain expertise in the ethical standards expected of expert witnesses; learn about the processes followed within legal cases when testifying on one's expert opinion; gain an understanding of the business aspects of a forensic counselor's work that breed success in this area of specialization.
Growth of the field
Job outlook
As of 2010 there were 129,800 working in the field. Jobs for rehabilitation counselors are expected to grow by 28 percent, which is much faster than the average for all occupations.
Professional development
There are several professional organizations Rehabilitation Counselors and other rehabilitation professionals belong to, including the American Rehabilitation Counseling Association, National Rehabilitation Counseling Association, and American Rehabilitation Action Network. Though there is no nationwide union or lobbying organization supporting rehabilitation counselors (such as is the case with social workers, or psychologists), the Commission on Rehabilitation Counselor Certification (CRCC) does a lot of work in organizing rehabilitation counselors that pursue the professional advancement of the young field.
See also
Career development
Commission on Accreditation of Rehabilitation Facilities
European Platform for Rehabilitation
Public service
Social change
Social development
References
External links
Rehabilitation Counseling Program at The University of Iowa
Rehabilitation Services Administration
Commission on Rehabilitation Counselor Certification
American Rehabilitation Counseling Association
National Rehabilitation Association
National Rehabilitation Counseling Association
NIU Rehabilitation Counseling - Deafness/Deaf-Blind Specialization
Michigan State University Rehabilitation Counseling Program
Counseling
| 0.774047 | 0.96949 | 0.75043 |
Integrated care
|
Integrated care, also known as integrated health, coordinated care, comprehensive care, seamless care, interprofessional care or transmural care, is a worldwide trend in health care reforms and new organizational arrangements focusing on more coordinated and integrated forms of care provision. Integrated care may be seen as a response to the fragmented delivery of health and social services being an acknowledged problem in many health systems. This model of care is working towards moving away from a siloed and referral-based format of care to a team-based model.
Central concepts
The integrated care literature distinguishes between different ways and degrees of working together and three central terms in this respect are autonomy, co-ordination, and integration. While autonomy refers to the one end of a continuum with least co-operation, integration (the combination of parts into a working whole by overlapping services) refers to the end with most co-operation and co-ordination (the relation of parts) to a point in between.
Distinction is also made between horizontal integration (linking similar levels of care like multiprofessional teams) and vertical integration (linking different levels of care like primary, secondary, and tertiary care).
Continuity of care is closely related to integrated care and emphasizes the patient's perspective through the system of health and social services, providing valuable lessons for the integration of systems. Continuity of care is often subdivided into three components:
continuity of information (by shared records),
continuity across the secondary–primary care interface (discharge planning from specialist to generalist care), and
provider continuity (seeing the same professional each time, with value added if there is a therapeutic, trusting relationship).
Integrated care seems particularly important to service provision to the elderly, as elderly patients often become chronically ill and subject to co-morbidities and so have a special need of continuous care.
The NHS Long Term Plan, and many other documents advocating integration, claim that it will produce reductions in costs or emergency admissions to hospital but there is no convincing evidence to support this.
Collaborative care
Collaborative care is a related healthcare philosophy and movement that has many names, models, and definitions that often includes the provision of mental-health, behavioral-health and substance-use services in primary care. Common derivatives of the name collaborative care include integrated care, primary care behavioral health, integrated primary care, and shared care.
The Agency for Healthcare Research and Quality (AHRQ) published an overview of many different models as well as research that supports them. These are the key features of collaborative care models:
Integration of mental health professionals in primary care medical settings
Close collaboration between mental health and medical/nursing providers
Focus on treating the whole person and whole family.
There are various national associations committed to collaborative care such as the Collaborative Family Healthcare Association.
a multiprofessional approach to patient care;
a structured management plan tailored to the individual needs of the patient;
proactive follow-up delivering evidence-based treatments;
processes to enhance interprofessional communication such as routine and regular team meetings and/or shared records.
According to Shivam Shah collaborative care is a form of systematic team-based care involving:
A case manager responsible for the coordination of different components of care;
A structured care management plan, shared with the patient;
Systematic patient management based on protocols and the tracking of outcomes;
Delivery of care by a multidisciplinary team which includes a psychiatrist;
Collaboration between primary and secondary care.
There are organizations in many countries promoting these ideas such as the American Collaborative Family Healthcare Association, a multi-guild member association based in Chapel Hill, North Carolina, which supports healthcare professionals in integrating physical and behavioral health. The University of Washington has an Advancing Integrated Mental Health Solutions Center, founded by Jürgen Unützer, to promote primary care behavioral health.
The Coalition for Collaborative Care was established in England in 2014. It focuses on re-framing the relationship between a person with long-term health conditions and the professionals supporting them.
Contrast to merging roles
The proper integrating of care does not mean the merging of roles. It remains uneconomical to make a physician serve as a nurse. Besides, the opposite approach is strictly prohibited by accreditation and certification schemes. The mix of staff for the various roles is maintained to enable a profitable integration in caring.
Examples
The United States Department of Veterans Affairs is the largest integrated care delivery system in the US.
Kaiser Permanente and the Mayo Clinic are the two largest private systems in the US.
Essential for the implementation of the integrated care program is a framework that guides the process. In Ireland, the Health Service Executive (HSE) is implementing an integrated care program according to a 10-Step Framework. This Framework is created along the recommendation of the World Health Organization.
See also
Case management (disambiguation)
Shared care
Team nursing
Integrated care system
GP Liaison
Health systems science
References
Health care
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Supported employment
|
Supported employment refers to service provisions wherein people with disabilities, including intellectual disabilities, mental health, and traumatic brain injury, among others, are assisted with obtaining and maintaining employment. Supported employment is considered to be one form of employment in which wages are expected, together with benefits from an employer in a competitive workplace, though some versions refer to disability agency paid employment. Companies such as Skilcraft in the United States are an example of "supported employment" which is defined in law for state and federal reimbursements (by person not by agency or corporation).
Community foundations of supported employment
Supported employment was developed in the United States in the 1970s as part of both vocational rehabilitation (VR) services (e.g., NYS Office of Vocational Services, 1978) and the advocacy for long term services and supports (LTSS) for individuals with significant disabilities in competitive job placements in integrated settings (e.g., businesses, offices, manufacturing facilities). Since the mid-1980s, supported employment in the professional literature primarily has referred to the "individual placement" model, either with job coaches or through "natural supports" models. The critical issue in supported employment (SE) was viewed as the need for funding for long-term services and supports (LTSS) in the community often termed beyond "case closure" (Griffin, Test, Dalton, & Wood, 1995). Supported employment is worldwide in 2013, though moving to new inclusive models, and the term has been used for assisting workers of diverse kinds who may need an extra jump start in the workplace; it is still associated with its roots in disability which includes community integration and deinstitutionalization.
University development of concept
Supported employment came from the community non-profit sector as an effort with government to offer services to individuals with significant disabilities, some of whom were moving from institutional life, in local communities for "supported work" (around the late 1970s). Community personnel entered rehabilitation programs, for degrees, and began an academic professionalization of the fields. Supported employment (SE) was on the rise nationally in the US in 1985 with growing university support, new dedicated agencies and programs, and preparation of master's and doctoral students in rehabilitation and education (e.g., Syracuse University, Rehabilitation Counseling, and Social Policy degrees). As an example, Thomas Bellamy, Larry Rhodes and Jay Albin of Oregon prepared a new chapter titled "Supported Employment" which indicated its uniqueness as having no entry requirement and no minimum ability levels (unheard of in vocational programs) in order to include candidates regardless of the nature or degree of their disability".
"Supported employment" was based upon principles of community integration and the site location termed an "integrated setting" was a core component of the applied and theoretical models (e.g., community integration theories, social role valorization, normalization, independent living theories, universal design). In addition, other critical aspects were paid work, vocational choices, employer development, school to work transition to job sites, and involvement of parents in the employment process. A Rehabilitation Research and Training Center (RRTC) on Supported Employment or related Employment and Disability areas has been funded in the university sector from the federal levels for over three decades under the leadership of Dr. Paul Wehman.
Diversity in supported employment models
By 1985, supported employment based on community integration had diverse vocational models in the US, including the social relationship concept of "disabled and non-disabled co-workers" working side-by-side in integrated workplaces (Nisbet & Callahan, 1987). Both consumers (self-advocates) and parents supported the new movement (in intellectual and developmental disabilities), seeking better opportunities for jobs, and later careers. A leading text on "Critical Issues in the Lives of People with Severe Disabilities" (Meyer, Peck & Brown, 1991) highlighted Supported Employment as one of the emerging practices with research already available on benefit-costs, consumer wages, social integration, and ongoing support (Rusch, Chadsey-Rusch, & Johnson, 1991).
In the psychiatric field, the prominent approach, also very innovative in long term services and supports (LTSS) was transitional employment associated with the now international Clubhouse Model of Fountain House in New York City. Gary Bond (1994) reported supported work as a modification of this approach. Paul Carling (1995) of the University of Vermont supported the development of community employment options in the field of psychiatric disabilities; Paul Wehman conducted critical cross-disability studies near the Medical School; Dr. Steven Murphy (1991) adapted employment supports for the psychiatric field; Julie Ann Racino confirmed related affirmative business and family models (e.g., Racino, 2003), and Dr. William Anthony (Anthony et al., 2002) of Boston University and his research center continues to work since the 1980s on a "get-choose-keep" approach to employment.
US legal basis
The legal "Integration" base for supported employment was described by Frank Laski, of The Public Interest Law Center in Philadelphia, Pennsylvania, (1985, April) as being the Education for All Handicapped Children Act (as revised by the Individual Disabilities Education Improvement Act) and the Rehabilitation Act of 1973 (amended 1978) passed by the US Congress. He also found strong support for moving from sheltered settings to supported employment in Developmentally Disabled Assistance and Bill of Rights Act (1975, as amended 1984) and fully supported a "zero reject" policy, individualized work plans, and questioning the notion of the "employability" concept.
Supported employment, emanating from the sheltered and governmental services sectors, has different roots than employment based upon traditional civil rights and discrimination approaches. Employment and disability often shares common roots with others disadvantaged in employment, based on discrimination due to gender, race, ethnicity, family structure, and disability, among other "differences" (e.g., Urban League of Onondaga County, Inc.). Such coalition based strategies emanate from the Civil Rights Act of 1964 and seek redress in employment based upon discrimination in hiring, promotions, terminations, and payments, among others. Such positions are not "dedicated positions", but may involve a reasonable accommodation (e.g., personal assistant, work desk modification) to perform the job as defined by the primary tasks of the employer-based system for "qualified individuals" Americans with Disabilities Act of 1990, now amended in 2008.
By 1991, proposed rules for the State Supported Employment Grant Program were published in the Federal Register for comment by the US Department of Education, and the announcement was made available to deaf and hearing impaired individuals through a TDD service (FR 56: 219.57776-57786). The Rehabilitation Services Administration (RSA)received comments, and the intent was to advance the program authorized under the Rehabilitation Act of 1973, Part C, as amended which supported disability rights in employment in the community. It also advanced the national goals of "literacy and "lifelong learning" for skills in the "global economy". in 2013, the US Department of Education, Office of Special Education and Rehabilitation, Rehabilitation Services Administration, issued a policy directive on supported employment (RSA-PD-13-02, April 30, 2013).
United States development of supported employment
In the United States, supported employment is defined in the Rehabilitation Act, as amended (1978). The more recent Rehabilitation Act Amendments were contained in the Workforce Investment Act signed into law in 1998. The Rehabilitation Act and its amendments establish and fund the Vocational Rehabilitation program. Vocational Rehabilitation, which is frequently referred to as "V.R.", is the core national employment program for persons with a disability, but is not the main agency to fund long-term services and supports (LTSS) in the community. Federal funding is funneled through state Vocational Rehabilitation agencies, and categorical state agencies and their regional offices (e.g., New York Office of People with Developmental Disabilities) are also involved, including Home and Community-Based (HCB) Medicaid Services Waiver funded programs nationwide.
Core definition
Here is a representation of the core definition of supported employment as it is contained in the Rehabilitation Act Amendments (Public Law 102-569: Supported Employment Definitions). Supported employment means:
A. Competitive employment in an integrated setting with ongoing support services for individuals with the most significant disabilities –
a) for whom competitive employment has not traditionally occurred; or
b) for whom competitive employment has been interrupted or intermittent as a result of significant disability; and
c) who, because of the nature and severity of their disabilities, need ongoing support services including both intensive initial support services and also extended services after transition from those initial support services in order to perform work; or
B. Transitional employment for individuals with the most significant disabilities due to mental illness.
There are a number of important critically important terms and concepts referenced in this definition of supported employment. These terms are:
Individuals with the most significant disabilities
Competitive employment
Integrated work setting
Ongoing support services and supported employment services.
The most common model of supported employment involves job coaching with the traditional rehabilitation approach to "fade services" into the work setting; however, supported employment has roots in long-term supports and services, and variations based upon "natural supports" (e.g., payments to a coworker to provide assistance).
Principles of Parents for Positive Futures were: real jobs in real workplaces, services for all, ongoing support, social integration, and individualized and flexible. Self advocates agreed with Real jobs for real pay, especially starting from "make work" in institutional settings.
In the vocational rehabilitation systems, concepts of working with business and industry, competitive employment (e.g., achieving existing job classifications and wages and benefits), transition to the workforces from schools, and traditional obstacles to work including competition, are all addressed in the VR systems.
Costs
Costs of supported employment have been an area of research and study since its inception, and include academic studies in categorical disability areas (e.g., psychiatric, traumatic brain injury) regarding long-term services in competitive settings (e.g., Wehman et al., 2003; Rogers et al., 1995).
Supported employment was designed to be cost-effective and cost-beneficial, and indeed has been documented to be so as a key community services in public administration and disability (Racino, in press, 2014). However, two cost trends are the medical center gates which change the cost structure and personnel (from collaboration between education and medical to medical operations; "physical restoration" by a "physiatrist"); and a government trend to cut the cost of its already lean services (e.g., natural supports to lower costs).
Cimera's 2012 review on the "economics of supported employment" indicated that:
1. Individuals fare better financially from working in the community rather than sheltered workshops, regardless of disability.
2. Relative wages earned by supported employees were up 31.2% since the 1980s, while sheltered workshop wages decreased.
Over 30 studies were reviewed in the 1980s and 1990s including in the US, Australia, Great Britain and Canada finding that "individuals with disabilities experience greater monetary benefits than costs when working in the community".
However, concerns regarding subminimum wage and employment extend to the community, especially due to the interplay of benefits, entry level versus skilled jobs, wages paid to the employee versus employer benefits, and dead end versus career approaches. However, early studies reported benefits of $1.97 to every dollar in cost with $13,815 in gross wages and fringe benefits to the employee (Hill et al., 1987) whom others viewed as "permanently unemployable" or "unable to work".
In addition, reviews of costs and benefits do not indicate the revenue streams for supported employment, especially when these programs can be one service of a large community "disability NGO" (non-governmental organization) and were eligible for Medicaid financing as early as 1991 (Smith & Gettings, 1991). Government itself in the late 2000s is increasingly concerned about costs, and vocational rehabilitation services, are being reviewed for their cost-effectiveness and ways to increase positive outcomes for clientele of their services
Employment supports
Supported employment evolved as a way to assist individuals with the most significant disabilities with employment in their communities...a real job for real pay, and involves personal assistance services including for people who lived in institutions in the US. For over 30 years supported employment has demonstrated that individuals with severe disabilities can work, yet today many individuals remain segregated in sheltered workshops and day programs. Efforts to convert sheltered workshops to provide supported employment (now, one person at a time) are underway, and a generation of Master's level students in Rehabilitation Counseling and Special Education have been educated in changing services and organizations from older, outdated segregation models to integrated vocational approaches in the community (e.g., Gardner, et al., 1988; Rogan & Racino, 1992). Verdicts in recent lawsuits upholding the right to work in inclusive settings seem to indicate that integrated employment will soon be the first choice.
Best practices dictate that an individualized support approach to supported employment, funded as a professional vocational rehabilitation service (now changing to infusion of risk and protective health factors), is used to assist individuals with gaining and maintaining employment (later, termed job retention). These practices may involve a supported employment service provider (professionals)to understand how to customize employment and provide supports, school personnel in transition, or it may involve an approach similar to bridgebuilding and person-centered community development. Supports could include: modifying a job, adding accommodations or assistive technology, enhancing on the job site training among other approaches, such as identifying network relationships (e.g., family business, local job sites and owners) and training parents regarding better futures. What is needed will vary from one person and one employer to the next, but do involve the human resource offices, the funding agencies, the supervisory levels, and even union leadership, among others. In 2010, customized employment, state employment first policies, and "revisiting key federal policies" are recommended as leadership in "employment of persons with severe disabilities"; however, with a newer movement toward the development of "non-work supports".
Early supported employment agency leaders, shifting from services to supports, included Jerry Kiracofe's Human Services Institute in Maryland (Kiracofe, 1994), Jeffrey Strully originally in Kentucky at Seven Counties Services (now, Rogan & Strully, 2007 in Colorado and California), Richard Crowley's area agency in New Hampshire (Rogan, 1992), ENABLE and Transitional Living Services in New York (the latter simply deciding in 1977 that "long term clients" in the community had a right to seek jobs and work, supported by "residential staff"), agencies in Oregon (Magis-Agosta, 1994), Wisconsin (Racino, 1987) and Great Britain, among others. These groups were associated also with research studies on job supports, workplace culture, and gender and ethnic concerns in employment structures. Supported employment was studied early in Canada in relationship to quality of life and an employment support worker (Pedlar, Lord & Loon, 1989).
Personal assistance services
Personal assistance services, a premier service of public policy and independent living, has a strong national and international research base dating back to the 1980s.(Litvak, Zukas & Heumann, 1987). Personal assistance services (PAS)has expanded to be an important component of "workplace supports" (Soloveiva, et al., 2010; Barcus & Targett, 2003) and is part of working schemes in countries such as Sweden (Clevner & Johansson, @2012). Personal assistance services and workplace PAS has been taught through Virginia Commonwealth University as an online course and is available in 2013 as a self-study through the independent living network.(http://www.worksupport.com/pas/funding.cfm) PAS has been developed for use by diverse groups, including in cognitive disabilities, inclusive of mental health, brain injuries and intellectual disabilities, and for individuals with medical and physical needs for assistance (Racino, 1995).
Natural supports
Natural supports models were funded by the federal and state governments, but public discussion of the concept and implementation has been lacking giving its relevance to workplaces and its federal research status (e.g., Butterworth et al., 1996). "Natural supports funding packages" were recommended by the university sector to state employment agencies with preferences for schemes which are based upon coworker training, the use of employment specialists to facilitate natural supports, and matching the supported employee with the natural supports of the worksites. Early models of "natural supports" were proposed by the rehabilitation community as part of research studies (e.g., Hagner, 1988), and knowing the colloquial paths of this approach international speaker Racino retorted, "What is natural about natural supports anyway?" The natural supports approaches were also aligned with related initiatives including empowerment and choice in employment, and gender differences in supported employment.
Reasonable accommodations as an employment support
One of the innovations from work with the Rehabilitation Act of 1973 as amended in 1978 was the application of the concept of reasonable accommodations to fields such as psychiatric disabilities. As part of deinstitutionalization efforts, now at the US Supreme Court's Olmstead Decision of 1999, "long-term services and supports" (LTSS) clients were seeking work in communities to support themselves (and sometimes families) in homes and daily lives. Systemic efforts were made to identify barriers to employment (e.g., Noble & Collignon, 1988), and legal avenues were also opened as described by Dr. Peter Blanck on the Americans with Disabilities Act of 1990. Reasonable accommodation allowed modifications on the job, while still retaining the competitive job site and pay grades in the community. The term "employment supports" was also applied to efforts to assist individuals which may come to the rehabilitation system with a "mental health diagnosis" (Marrone, Bazell, & Gold, 1995). These efforts may resemble those termed "natural supports" since job retention (involving coworkers and supervisors), as opposed to job placement (a traditional rehabilitation counselor function) may be key.
Systems change
Supported employment was visualized as a way to change segregated services systems, based largely upon sheltered workshop facilities, to an integrated community approach to employment for individuals, primarily with intellectual and developmental disabilities. For example, in 1995, California leaders Steve Zivolich and Jan Weiner-Zivolich inquired of the provider and governmental sectors: "If Not Now, When?: The Case Against Waiting for Sheltered Workshop Changeover". However, while full conversion has not occurred with growth also in adult day programs, new principles in employment have been promoted through the national APSE Network for Employment. These principles include quality indicators on individual choice and control of resources and supports.
Conversion of sheltered workshops was recommended in the 1990s as part of the effort to shift financing and services to integrated settings. State trends in "conversion" to integrated work have been monitored by the Institute for Inclusion in Boston and are available on the internet.
"Local community rehabilitation agencies providing supported employment grew from just over 300 in 1986 to approximately 5,000 in 1993" (McCaughey et al., 1995). However, Wehman and Kregel (1995) indicated that supported employment was established in every state through Title III, Part C of the Rehabilitation Act Amendments in 1986; Gary Smith with Bob Gettings indicated all states were funded for supported employment under the Home and Community-Based Medicaid Waivers, too. Supported employment remains a viable employment option and operates side-by-side with segregated employment options within states in the US and involved 212,000 individuals with severe disabilities in 2002 (Rusch & Braddock, 2004).
Racino (1994) reported (conceptual schemes) that the changes required in areas termed "support services" require other than the traditional "organizational" or "systems change" strategies of professional education and training. For example, in a study involving herself, the VR system continued to revert to the 1970s "entry level" position as the agreed upon (employer-school-service provider)approach to personnel with high educational degrees and extensive work experiences (i.e., one size fits all) similar to parents of children with disabilities who might be in entry-level jobs with high degrees. These issues have been termed "attitudinal" problems or lowered expectations and aspirations for people with disabilities which may emanate from the employers, the public, or from the service workers themselves. In addition, traditional barriers schemas target the agency management and regulatory and legislative bodies as intransegient in modernization.
Individual Placement Model (IPS)
IPS Supported Employment helps people with severe mental illness work at regular jobs of their choosing. Although variations of supported employment exist, IPS (Individual Placement and Support) refers to the evidence-based practice of supported employment (as Annie Oakley explains, referring to "everything under the sun") as validated by new universities and medical centers involved in employment. The model appears to be a variation of professional supported employment approaches, based on decades of research study and practice in the field of disabilities.
Characteristic of IPS Supported Employment
It is an evidence-based practice
IPS supported employment practitioners focus on client strengths
Work can promote recovery and wellness
Practitioners work in collaboration with state vocational rehabilitation
It uses a multidisciplinary team approach
Services are individualized and long-lasting
The IPS approach changes the way mental health services are delivered
Another earlier model was termed the hybrid case management/supported employment model which was reported on by Carol Mowbray of the University of Michigan, who studied mental health services nationwide, as a WINS research and demonstration model. These models critique earlier models and goals such as zero reject and "linear models" and emphasize the comprehensive planning aspects of multi-agency "individual placements".
The New Hampshire-Dartmouth Psychiatric Research Center considers day treatment programs, often previously known as day habilitation programs in the community, and supported employment (totally community developed and rigorously tested outside the categorical psychiatric services) to be two kinds of comparative outpatient services. This research group, following others in the US, reaffirms that supported employment can improve outcomes such as integration. Day treatment is also a set of "educational, counseling, and family interventions" which may be used for children and youth per Krista Kutash of Florida's Research Center for Children with Emotional Needs (1996); whereas these "support services" may be applicable for adults, supported employment (SE) typically is an adult service and for youth transitioning to work settings.
By 2006, supported employment was part of a web-based certificate series with a new certificate for "supported competitive employment for individuals with mental illness" (Virginia Commonwealth University, 2006). Typically, the audience are service providers who offer vocational and supported employment services ("university technical assistance and training"); these services build upon both traditional funded vocational rehabilitation categories (e.g., work adjustment) and newer concepts of career development versus jobs and job placements.
Education and training
Supported employment, commonly a community service in the fields of rehabilitation, has roots both in the university sector, the vocational rehabilitation state and regional offices, and in the categorical service system of intellectual and developmental disabilities (long-term services and supports). As early as the mid-1980s, supported employment was an accepted inservice training topic with extensive working papers, videotapes, presentations, case studies, written books and products, and very reputable network of university personnel, including in severe disabilities. As indicated above, university certificates have been available since the mid-2000s on the web, and even earlier from the university sector preonline courses (see, Racino, 2000). Certification is highly recommended, and indeed in most "providing sectors" needs to be required as providers tend to self-certify only. Traditional rehabilitation programs expected all rehabilitation personnel education programs to prepare for integrative and competitive employment as early as the 1980s.
Early skills recommended were both generic professional helping skills (e.g., facilitator, motivator, coach) and specific employment-related skills for workers (e.g., job sharing, job coaching). In addition, exceptional skills are required and more (e.g., political, social, administrative, health-human services) for conversion of traditional day programs to integrated employment systems. Marc Gold's Michael Callahan, after tackling the institutional populations (Marc Gold in the 1970s), was one of the 4 decade or more leaders to community employment supporting the provider sector.
Special populations
Autism
In the 21st century, autism is a primary "disability" that frames the progressive advances in the community services fields (e.g., Consortium of Citizens with Disabilities, Task force on autism and family support, 2018). The special issue of the Journal of Vocational Rehabilitation was published in January 1994 (Volume 4, No. 1) with Marcia Datlow Smith as Editor. The focus has a behavioral emphasis and the concept and realities of supported employment are considered revolutionary for "children who had difficulty in communication, speech, and the world in their immediate space." The issue includes a study of 70 individuals with autism served by the Community Services for Autistic Adults and Children (CSSAC) in state of Maryland.
Brain injury
Community services in head and brain injury took on a new priority in the 1990s, and for the first time, work and living options were explored in conjunction with the newly formed state associations of head injury administrators. These services were scientifically studied in states such as New York at their Buffalo and Syracuse university centers in the context of changing public policy. The traditional rehabilitation concept of return to work was also developed in depth at the university sector with the relatively new cognitive rehabilitation or cognitive remediation.
Mental health and intellectual disabilities
While for categorical state and local NGOs, work and community employment was accepted relatively early on (1970s and 1980s) as possible but difficult in "severe mental illness", but changing the state-federal vocational rehabilitation system was considered more difficult. In 1993, John Kregel at the International Association of Persons with Severe Handicaps, reported that individuals with severe intellectual disability, autism, physical disabilities and other groups continue to compromise a small percentage of supported employment participants. A systematic review investigated the effects of supported employment for adults with severe mental illness:
Women and Supported Employment: Gender
The university sector leaders in supported employment in the 1980s included Parents for Positive Futures which were women and men (e.g., Kathy Hayduke), women CEOs of non-profit organizations (who also were parents of children with disabilities, Josephine Scro), women state and NGO management (e.g., Sheila Harrigan, first CEO of NYSACRA), and women university professionals and researchers (e.g., "controlled for gender, age, disability, household size, race and ethnicity"). In addition, it was not until decades later that the complexity of gender and its role in the workforce (See, women's professions, and disability and gender, post-Adrienne Asch) began to appear in the American literatures "with special population women management".
In part this discrepancy was due to what was termed the "male education of high women in America", such as this author's over 40 male professors and 2 women professors (one visiting from out-of-state, and another not obtaining tenure) for her bachelor's degree at Cornell University in 1975 (e.g., Racino, 2014). Our Nordic lead began with gender perspectives on family caregiving and published "in house" (Rehabilitation Research and Training Center on Community Integration) a supported employment bibliography from gender perspectives (Traustadottir, 1990-. p.s., the daughter of Trausta).
In addition, the major federal research center in "mental retardation/intellectual and developmental disabilities" in the US has been "male-led" as director, associate director and Technical Assistance to US States) for over 3 decades (Rehabilitation Research and Training Center on Supported Employment, and variations) (e.g., Wehman, 1993; Wehman & Kregel, 1994) However, women have held key roles in labor and disability, including Suzanne Bruyere of Cornell University ILR (Industrial and Labor Relations) School. Since supported employment is a subset of employment and now business entrepreneurships, analyses of its role and effects in the broader employment studies is still open for further research.
Other countries
"No matter whether they live in the most prosperous nations of the world or the least, people with disabilities are among the most economically disadvantaged groups in society." (Schriner, 2001).
Other countries around the globe use the terminology 'supported employment' and each one has its own definition. In 1995, Steven Byer who visited the US from the United Kingdom, authored a chapter on Real jobs and supported employment for a leading book, Values and Visions by the King's Fund Linda Ward (with Philpot). Prior to that book, Britain's Ordinary Lives leader David Towell (with Beardshaw) cited the US supported employment in "Enabling Community Integration" to assist public authorities in the UK to move toward integration in community life. In 2012, the Journal of Vocational Rehabilitation (JVR) highlighted the status in the European Union, inclusive of Germany, Norway and the Scandinavian countries (e.g., Iceland, Denmark), and the United Kingdom. In particular, the European Union on Supported Employment is examining inclusion skills competencies.
Supported employment remains underdeveloped, in spite of its years of available direct university education and training to the provider, financing and regulatory sectors. In the US, the inquiry can and has been made to state and local governments: "Where are the successes?" based on the decades of infusion of funds, assistance, exemplars, for "state systems change". The Journal of Vocational Rehabilitation (JVR) celebrated its 20th anniversary in 2011 under the leadership of Dr. Paul Wehman, and over 3,000 special education or inclusion teachers annually learn of new developments (e.g., social capital, ethnic and cultural issues, business and marketing, supported employment developments) at the International Association of Persons with Severe Handicaps (TASH) Annual Conference.
Stefan Doose of Germany (2012) indicates a new federal Inklusion program (2011 from 2018) which promotes transition from school to work, and from sheltered workshops direct to the labor markets. Great Britain supported opportunities for Ordinary Lives, which included moving from day centres to supported employment as early as the late 1980s (Towell & Beardshaw, 1991).
Today, the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD, 2006) supports the right to employment, among its articles ratified by over 100 countries and in the implementation stages.
Supported employment services may be provided as direct vocational support to job seekers with disabilities, or in the form of affecting demand for labor through employment policies. From an international perspective, examples of employment schemes used on employers to generate an expansion of job opportunities for persons with disabilities (PWDs) include employment incentive structure and minimum employment quota. The employment incentive system is a financial measure taken in an open employment environment to integrate PWDs into the workforce and may encompass benefits such as wage subsidies and funding for adaptations to the work environment. The minimum employment quota is a legislative affirmative action that attempts to create equal opportunity for persons with disabilities by ensuring that a proportion of employees consist of PWDs. The two schemes are not mutually exclusive and may be used in hybridity.
Asia
Hong Kong
The Labor Department of Government of Hong Kong's Labour and Welfare Bureau provides free supported employment services under the Selective Placement Division (SPD), which was established in 1980. The SPD launched the Work Orientation and Placement Scheme (WOPS) in 2013, serving to incentivize employers to hire job seekers with disabilities. Through WOPS, participating employers are granted a maximum total allowance of 51,000 HKD per employee with disabilities who have employment difficulties and 30,000 HKD per employee with disabilities who do not employment difficulties. The allowance, respectively, is divided through nine months and six months of employment. The employers participating in WOPS are required to have a mentor staff that can provide on-the-job support for the new employee, and the length of the employment contract must be 3 months or longer. Furthermore, WOPS provides short term pre-employment training to job seekers to strengthen their chance of employment. After completing the pre-employment training, the trainees receive an allowance of $80 per training day.
The Social Welfare Department of the Labour and Welfare Bureau also provides employment assistance to job seekers with disabilities through Supported Employment (SE) and Support Programme for Employees with Disabilities (SPED). SE provides sheltered workshops to train individuals with disabilities that are unable to obtain open employment. SE service includes employment counseling, job finding and matching, follow-through support and employment-related skills training. On the other hand, SPED is an incentive system for the employers initiated in 2014 to aid employees with disabilities to retain their status as an employee in open employment. SPED provides one-off-subsidy to participating employers for modifying the workspace to accommodate for special needs or equipping the workplace with assistive devices that can enhance the work efficiency of workers with disabilities. The level of subsidy is capped at 20,000 HKD per employee with disabilities.
Singapore
Initiated by the Workforce Development Agency (WDA) and the Ministry of Social and Family Development (MSF) in 2014, the Open Door Programme (ODP) encourages employers to provide employment opportunities to individuals with disabilities and to create an accessible work environment for the employees with special needs. Through the ODP, the employers receive Job Redesign Grant up to 20,000 SGD per employee with disabilities, supporting up to 90% of the costs of redesigning the job scopes to accommodate the employees' conditions. Moreover, the employers are incentivized to provide special training for PWDs as 90% of the training course fee is funded by the ODP. As of 2015, the Government of Singapore has subsidized 3.2 million SGD through the Open Door Fund.
In addition, the Special Employment Credit (SEC) started to provide budget initiatives to the employers in 2012 by funding 16% of the monthly wages of employees with disabilities who earn up to 4,000 SGD per month. To encourage re-employment, Additional Special Employment Credit, which funds 22% of the employee's monthly wages, was initiated in 2015 as an amendment to the SEC program. Singapore Workforce Development Agency also provides Workfare Schemes, which tops up the wages of the employees with Workfare Income Supplement (WIS) and encourages employers to educate the employees with Workfare Training Support (WTS). WIS provides annual payouts capped at 4,000 SGD in terms of monthly cash and life annuity scheme called Central Provident Fund to aid expenditure and retirement savings for employees with disabilities. WTS subsidizes 95% of the training fees in addition to 95% of absentee payroll for the employee in training.
China
China Disabled Persons' Federation (CDPF), a national nonprofit organization founded in 1988, provides supported employment to job seekers with disabilities through free services such as consultation, rehabilitation and training for employment, and job referrals.
In 2008, a quota system that aims to protect the employment of persons with disabilities was established under Regulations on the Employment of Persons with Disabilities, through which the Chinese Government mandates all public and private organizations to secure at least 1.5% of job opportunities to PWDs. The exact percentage of quota varies amongst different provinces in China but is no less than 1.5%. Employers that fail to meet the quota must pay proportionate amounts of penalty to the Disabled Employment Security Fund (DESF). The revenue resulting from the levies is disbursed to provide supported employment in forms of vocational training and job placement career services. Employers that satisfy or surpass the quota are subsidized through taxation benefits, cash rewards and technical assistance to incentivize employment of job seekers with disabilities.
Regulations on the Employment of Persons with Disabilities also encourage self-employment by assisting PWDs with starting their own enterprises. The government helps PWDs who engage in entrepreneurial activities by providing tax exemptions and assistance in obtaining a workplace and licenses.
Canada
The Canadian Association for Supported Employment (CASE) works with employment service providers, employers, community allies, and other stakeholders to facilitate full participation in the labour force for people with disabilities by offering resources, expertise, and advocacy.
See also
Specialisterne
References
External links
Irish Association of Supported Employment
Disability employment Services
Wage Subsidies and Incentives for Employers
British Association for Supported Employment |
Disability in the United States
Employment classifications
Developmental disabilities
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Lifestyle medicine
|
Lifestyle medicine (LM) is a branch of medicine focused on preventive healthcare and self-care dealing with prevention, research, education, and treatment of disorders caused by lifestyle factors and preventable causes of death such as nutrition, physical inactivity, chronic stress, and self-destructive behaviors including the consumption of tobacco products and drug or alcohol abuse. The goal of LM is to improve individuals' health and wellbeing by applying the 6 pillars of lifestyle medicine (nutrition, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection) to prevent chronic conditions such as cardiovascular diseases, diabetes, metabolic syndrome and obesity.
Lifestyle medicine focuses on educating and motivating patients to improve the quality of their lives by changing personal habits and behaviors around the use of healthier diets which minimize ultra-processed foods such as a Mediterranean diet or whole food, plant-predominant dietary patterns. Poor lifestyle choices like dietary patterns, physical inactivity, tobacco use, alcohol addiction and dependence, drug addiction and dependence, as well as psychosocial factors, e.g. chronic stress and lack of social support and community, contribute to chronic disease. In the clinic, major barriers to lifestyle counseling are that physicians feel ill-prepared and are skeptical about their patients' receptivity. However, by encouraging healthy decisions, illnesses can be prevented or better managed in the long-term.
Characteristics
Lifestyle Medicine in Practice
Lifestyle interventions require behavior changes that may be challenging for health professionals, communities, and patients. The task of the LM practitioner is to motivate and support healthy behavior changes through evidence-based approaches to prevent and manage chronic conditions. LM emphasizes personalized care and uses patient-centered approaches such as goal-setting, shared decision-making, and self-management. Coaching patients how to cook healthy food at home, for example, can be part of a lifestyle-oriented medical practice. Focusing on the health needs of an individual includes looking at the person's social and economic needs, as well.
LM uses behavioral science to equip and encourage patients to make lifestyle changes. There are many theories of behavior change; the transtheoretical model is particularly suited to lifestyle medicine. It posits that individuals progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Stage-matched interventions are most likely to result in successful behavior changes. LM practitioners are encouraged to adopt counseling methods such as motivational interviewing (MI) to identify patient readiness to change and provide stage appropriate lifestyle interventions. These skills have shown to be more effective than giving advice like "Exercise more and eat healthy".
LM is similar to preventive medicine in that it also bridges the gap between conventional medicine and public health. LM interventions such as behavioral change counseling are used in adjunct with pharmacotherapy. Like all of medicine, LM promotes healthy lifestyle choices to prevent and treat diseases. Overall wellness and self-management are a crucial components of lifestyle medicine and enforce the idea of living healthier through behavioral change. Health promotion is the foundation of LM and encourages individuals to participate in their own care and well-being.
Levels of Lifestyle Medicine
LM may be practiced on three levels. The first level involves recognition by all healthcare professionals that lifestyle choices determine health status and are important modifiers of the response to pharmaceutical and/or surgical treatments. All practitioners are encouraged to include lifestyle advice along with standard treatment protocols. The second level is specialty care (e.g., Exercise medicine and Physiatry) in which LM interventions are the focus of treatment and pharmaceutical and/or surgical treatments are an adjunct to be used as necessary. The third level is population/community health programs and policies. Lifestyle intervention advice should be included in public health/preventive medicine guidance and policies for the prevention and treatment of chronic diseases.
Interprofessional Education/Collaboration in Lifestyle Medicine Practice
Healthcare professionals and their future patients would benefit if the basics of LM were incorporated into all professional training programs. Formal training and personal experience of evidence-based lifestyle interventions such as plant-based nutrition, stress management, physical activity, sleep management, relationship skills, and substance abuse mitigation would transform the American healthcare system. LM is uniquely suited to interprofessional education in which students from two or more healthcare professions learn together during professional training with the objective of cultivating collaborative practice of patient-centered care. Physicians and other healthcare providers should feel comfortable talking with their patient about behavioral lifestyle changes and assessing needs in determinants of health. Engaging patients in these conversations can better help them achieve their lifestyle and healthcare goals.
There are many educational pathways to becoming an expert in LM. Physicians can become certified or accredited from the International Board of Lifestyle Medicine (IBLM), American Board of Lifestyle Medicine (ABLM), and British Society of Lifestyle Medicine (BSLM). The Lifestyle Medicine Global Alliance (LMGA) is an organization that connects LM professionals from nations around the world to collaborate, share resources, and create solutions to preventing and reversing non-communicable and chronic diseases.
See also
Active living
References
Further reading
External links
Health education
Health promotion
Lifestyle
Practice of medicine
Preventive medicine
Public health education
Public health research
Self-care
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Medical sociology
|
Medical sociology is the sociological analysis of health, Illness, differential access to medical resources, the social organization of medicine, Health Care Delivery, the production of medical knowledge, selection of methods, the study of actions and interactions of healthcare professionals, and the social or cultural (rather than clinical or bodily) effects of medical practice. The field commonly interacts with the sociology of knowledge, science and technology studies, and social epistemology. Medical sociologists are also interested in the qualitative experiences of patients, doctors, and medical education; often working at the boundaries of public health, social work, demography and gerontology to explore phenomena at the intersection of the social and clinical sciences. Health disparities commonly relate to typical categories such as class, race, ethnicity, immigration, gender, sexuality, and age. Objective sociological research findings quickly become a normative and political issue.
Early work in medical sociology was conducted by Lawrence J Henderson whose theoretical interests in the work of Vilfredo Pareto inspired Talcott Parsons interests in sociological systems theory. Parsons is one of the founding fathers of medical sociology, and applied social role theory to interactional relations between sick people and others. Later other sociologists such as Eliot Freidson have taken a conflict theory perspective, looking at how the medical profession secures its own interests. Key contributors to medical sociology since the 1950s include Howard S. Becker, Mike Bury, Peter Conrad, Jack Douglas, Eliot Freidson, David Silverman, Phil Strong, Bernice Pescosolido, Carl May, Anne Rogers, Anselm Strauss, Renee Fox, and Joseph W. Schneider.
The field of medical sociology is usually taught as part of a wider sociology, clinical psychology or health studies degree course, or on dedicated master's degree courses where it is sometimes combined with the study of medical ethics and bioethics. In Britain, sociology was introduced into the medical curriculum following the Goodenough report in 1944: "In medicine, 'social explanations' of the etiology of disease meant for some doctors a redirection of medical thought from the purely clinical and psychological criteria of illness. The introduction of 'social' factors into medical explanation was most strongly evidenced in branches of medicine closely related to the community — Social Medicine and, later, General Practice" .
History
Samuel W. Bloom argues that the study of medical sociology has a long history but tended to be done as one of advocacy in response to social events rather than a field of study. He cites the 1842 publication of the sanitary conditions of the labouring population of Great Britain as a good example of such research. This medical sociology included an element of social science, studying social structures as a cause or mediating factor in disease, such as for public health or social medicine.
Bloom argues the development of medical sociology is linked to the development of sociology within American universities. He argues that the 1865 creation of the American Social Science Association (ASSA) was a key event in this development. ASSA's initial aim was policy reform on the basis of science. Bloom argues that over the next few decades the role of ASSA moved from advocacy to academic discipline, noting that a number of academic professional bodies broke away from the ASSA during this period, starting with the American Historical Association in 1884. The American Sociological Society formed in 1905.
The Russell Sage Foundation, formed in 1907, was a large philanthropic organization which worked closely with the American Sociological Society, which had medical sociology as a primary focus of its suggested policy reform. Bloom argues that the presidency of Donald R Young, a professor of sociology, that started in 1947 was significant in the development of medical sociology. Young motivated by a desire to legitimize sociology, encouraged Esther Lucile Brown, an anthropologist who studied the professions, to focus her work on the medical professions due to medicine's societal status.
Harry Stock Sullivan
Harry Stack Sullivan was a psychiatrist who investigated the treatment of schizophrenia using approaches of interpersonal psychotherapy working with sociologists and social scientists including Lawrence K. Frank, W. I. Thomas, Ruth Benedict, Harold Lasswell and Edward Sapir. Bloom argues that Sullivans work, and its focus on putative interpersonal causes and treatment of schizophrenia influenced ethnographic study of the hospital setting.
The Medical Profession
The profession of medicine has been studied by sociologists. Talcott Parsons looked at the profession from a functionalist perspective, focusing on medics roles as experts, their altruism, and how they support communities. Other sociologists have taken a conflict theory perspective, looking at how the medical profession secures its own interests. Of these, Marxist conflict theory perspective considers how the ruling classes can enact power through medicine, while other theories propose a more structural pluralist approach, exemplified by Eliot Freidson, looking at how the professions themselves secure influence.
Medical Education
The study of medical education was a central part of the medical sociology since its emergence in the 1950s. The first publication onn the topic was Robert Merton's, The Student Physician. Other scholars who studied the field include Howard S. Becker, with his publication, Boys in white.
The hidden curriculum is a concept in medical education that refers to a distinction between what is officially taught and what is learned by a medical student. The concept was introduced by Philip W. Jackson in his book, Life in the classroom, but developed further by Benson Snyder. The concept have been criticised by Lakomski and there was considerable debate on the concepts within the educational community.
Medical Dominance
Writing the 1970s Eliot Freidson argued that medicine had reached a point of "Professional Dominance" over the content of their work, other health professions and their clients by convincing the public of medicine's effectiveness, gaining a legal monopoly over their work, and appropriating other "medical" knowledge through control of training. This concept of dominance was extended to professions as a whole in closure theory, where professions were seen as competing for scope of practice, for example in the work of Andrew Abbott. Coburn argued that the academic interest in medical dominance decreased over time due to the increased role of capitalism in healthcare in the US, challenges to the control of health policy by politicians, economists and planners, and increased agency of patients through their access to the internet. Kath M. Melia, sociologist nursing professor, argued that, so far as nurses were concerned the medical 'paternalistic' attitudes remained.
Medicalization
Medicalization describe the process whereby an ever wider range of human experiences are understood is defined, experienced and treated as a medical condition. Examples of medicalization can be seen in deviance such as defining addiction or antisocial personality disorder as a medical condition. Feminist scholars have shown that the female body is prone to medicalization, arguing that the tendency of viewing the female body as the other has been a factor in this.
Medicalization can obscure social factors by defining a condition as existing entirely within an individual and can be depoliticizing, suggesting than an intervention should be medical when the best intervention is political. Medicalization can give the profession of medicine undue influence.
Social construction of illness
Social constructionists study the relationships between ideas about illness and expression, perception and understanding of illness by individuals, institutions and society. Social constructionists study why diseases exist in one place and not another, or disappear from a particular area. For example, premenstrual syndrome, anorexia nervosa and susto appear to exist in some cultures but not others.
There are a broad range of social constructionist frameworks used in medical sociology that make different assumptions about the relationships between ideas, social processes and the material world. Illnesses vary in the degree to which their definition is socially constructed and some illnesses are straightforwardly biologically. For these straightforwardly biologically diseases it would not be meaningful to describe them a social construction, though it might be meaningful to study the social processes that resulted in the discovery of the disease.
Some illnesses are contested when someone complains about a disease despite the medical community being unable to find a biological mechanism for disease. Examples of contested diseases include myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia and Gulf War syndrome. For contested diseases can be studied as social constructs but there is no biomedical understanding. Some contested diseases, such as ME/CFS, are accepted by the institutions of biomedicine while others, such as environmental diseases, are not.
Sick role
The study of the social construction of illness within medical sociology can be traced to Talcott Parsons notion of the sick role. Talcott Parsons introduced the notion of the sick role in his book The Social System. Parsons argued that the sick role is a social role approved and enforced by social norms and institutional behaviours where an individual is viewed as showing certain behaviour because they are in need of support.
Parsons argues that defining properties are that the sick person is exempt from normal social roles, that they are not "responsible" for their condition, that they should try to get well, and that they should seek technically competent people to help them.
The concept of the sick role was critiqued by sociologists from a neo-marxist, phenomonological and social interactionist perspective, as well as by those with an anti-establishment viewpoint. Burnham argues that part of this criticism was a rejection of functionalism due to its associations with conservatism. The sick role fell out of favour in the 1990s.
Labelling theory
Labelling theory derived from work by Howard S. Becker who studied the sociology of marijuana use. He argued that norms and deviant behaviour are partly the result of the definitions applied by others. Eliot Freidson applied these concepts to illness.
Labelling theory separates the aspects of an individual's behaviour that is caused by an illness, and that which is caused by the application of a label. Freidson distinguished labels based on legitimacy and the degree to which to this legitimacy affected an individual's responsibilities.
Labelling theory has been criticized on the ground that it does not explain which behaviours are labelled as deviant and why people engage in behaviours which are labelled as deviant: labelling theory is not a complete theory of deviant behaviour.
Mental health
An illness framework is the dominant framework for disease in psychiatry and diagnosis is considered worthwhile. Psychiatry has emphasizes the biological when considering mental illness. Some psychiatrists have criticized this model: some prefer biopsychosocial definitions, some prefer social constructionist models, others have argued that madness is an intelligent response if all circumstances are understood (Laing and Esterson). Thomas Szasz, who trained as psychiatrist, argued that mental health was a bad concept in his 1961 book, The Myth of Mental Illness, arguing that minds can only be ill metaphorically.
The Doctor-Patient relationship
The doctor–patient relationship, the social interactions between healthcare providers and those who interact with them, is studied by medical sociology. There are different models for the interaction between a patient and doctor, which may have been more or less prevalent at different times. One such model is medical consumerism that has partly given way to patient consumerism.
Medical Paternalism
Medical paternalism is the perspective that doctors want what is best for the patient and must take decisions on behalf of the patient because the patient is not competent to make their own decisions. Parsons argued that though there was an asymmetry of knowledge and power in the doctor patient relationship the medical system provided sufficient safeguards to protect the patient justifying a paternalistic role by the doctor and medical system.
A system of medical paternalism was prominent following the second world war through to the mid-1960s. Writing in the 1970s, Eliot Freidson referred to medicine as having "professional dominance", determining its work and defining a conceptualization of the problems that are brought to it and the best solutions to them. Professional dominance is defined by three characteristics: practitioners having power over clients, for example through dependency, knowledge, or location asymmetry; control over juniors in the field, requiring juniors deference and submission; and control over other professions either by excluding them from practice, or placing them under control of the medical profession.
Yeyoung Oh Nelson argues that this system of paternalism was in part undermined by organizational change in the following decades in the US whereby insurance companies, managers and the pharmaceutical industry started competing for role of conceptualizing and delivering medical services, part of the motive being cost saving.
Bioethics
Bioethics studies ethical concern in medical treatment and research. Many scholars believe that bioethics arose due to a perceived lack of accountability of the medical profession, the field has been broadly adopted with most US hospitals offering some form of ethical consultation. The social effects of the field of bioethics have been studied by medical sociologists. Informed consent, having its roots in biothetics, is the process by which a doctor and a patient agree to a particular intervention and has. Medical sociology study the social processes that influences and at times limit consent.
Related fields
Social medicine
Social medicine is a similar field to medical sociology in that it tries to conceptualize social interactions in investigating how the study of social interactions can be used in medicine. However, the two fields have different training, career paths, titles, funding and publication.In the 2010s, Rose and Callard argued that this distinction may be arbitrary.
In the 1950s, Strauss argued that it was important to maintain the independence of medical sociology from medicine so that there was a different perspective on sociology separate from the aims of medicine. Strauss feared that if medical sociology started to adopt the goals expected by medicine it risked losing its focus on analysing society. These fears that have been echoed since by Reid, Gold and Timmermans. Rosenfeld argues that the study of sociology focused solely on making recommendations for medicine has limited use for theory building and its findings cease to apply in different social situations.
Richard Boulton argues that medical sociology and social medicine are "co-produced" in the sense that social medicine responds to the conceptualization of medical practices created by medical sociology and alters medical practice and medical understanding in response, and that the effects of these changes are then analyzed by medical sociology once again. He argues that the tendency to view certain theories such as the scientific method (positivism) as the basis for all knowledge, and conversely the tendency to view all knowledge as associated with some activity both risk undermining the field of medical sociology.
Medical anthropology
Peter Conrad notes that medical anthropology studies some of the same phenomena as medical sociology but argues that medical anthropology has different origins, originally studying medicine within non-western cultures and using different methodologies. He argues that there was some convergence between the disciplines, as medical sociology started to adopt some of the methodologies of anthropology such as qualitative research and began to focus more on the patient, and medical anthropology started to focus on western medicine. He argues that more interdisciplinary communication could improve both disciplines.
See also
Epidemiological transition
Gothenburg Study of Children with DAMP
Health disparities
Medicalization
Sociology of health and illness
Stroke Belt
References
Further reading
Medicine in society
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Human relations movement
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Human relations movement refers to the researchers of organizational development who study the behaviour of people in groups, particularly in workplace groups and other related concepts in fields such as industrial and organizational psychology. It originated in the 1930s' Hawthorne studies, which examined the effects of social relations, motivation and employee satisfaction on factory productivity. The movement viewed workers in terms of their psychology and fit with companies, rather than as interchangeable parts, and it resulted in the creation of the discipline of human relations management.
Mayo's work
Elton Mayo stressed the following:
The power of natural groups, in which social aspects take precedence over functional organizational structures.
The need for reciprocal communication, in which communication is two way, from worker to chief executive, as well as vice versa.
The development of high quality leadership to communicate goals and to ensure effective and coherent decision making.
It has become a concern of all many companies to improve the job-oriented interpersonal skills of employees. The teaching of these skills to employees is referred to as "soft skills" training. Companies need their employees to be able to successfully communicate and convey information, to be able to interpret others' emotions, to be open to others' feelings, and to be able to solve conflicts and arrive at resolutions. By acquiring these skills, the employees, those in management positions, and the customer can maintain more compatible relationships.
Arguments against Mayo's involvement in human relations
Mayo's work is considered by various academics to be the basic counterpoint of Taylorism and scientific management. Taylorism, founded by Frederick W. Taylor, sought to apply science to the management of employees in the workplace in order to gain economic efficiency through labour productivity. Elton Mayo's work has been widely attributed to the discovery of the 'social person', allowing for workers to be seen as individuals rather than merely robots designed to work for unethical and unrealistic productivity expectations. However, this theory has been contested, as Mayo's purported role in the human relations movement has been questioned. Nonetheless, although Taylorism attempted to justify scientific management as a holistic philosophy, rather than a set of principles, the human relations movement worked parallel to the notion of scientific management. Its aim was to address the social welfare needs of workers and therefore elicit their co-operation as a workforce.
The widely perceived view of human relations is said to be one that completely contradicts the traditional views of Taylorism. Whilst scientific management tries to apply science to the workforce, the accepted definition of human relations suggests that management should treat workers as individuals, with individual needs. In doing so, employees are supposed to gain an identity, stability within their job and job satisfaction, which in turn make them more willing to co-operate and contribute their efforts towards accomplishing organisational goals. The human relations movement supported the primacy of organizations to be attributed to natural human groupings, communication and leadership. However, the conventional depiction of the human relations 'school' of management, rising out of the ashes of scientific management is argued to be a rhetorical distortion of events.
Firstly, it has been argued that Elton Mayo's actual role in the human relations movement is controversial and although he is attributed to be the founder of this movement, some academics believe that the concept of human relations was used well before the Hawthorne investigations, which sparked the human relations movement. Bruce and Nyland (2011) suggest that many academics preceded Mayo in identifying a concept similar to that of the human relations movement even going as far to suggest that the output and information collected by the Hawthorne investigations was identified well before Mayo by Taylor. In addition, Wren and Greenwood (1998) argue that Taylor made important contributions to what inspires human motivation, even though his ultimate findings were somewhat different from the human relations movement.
Another name which has been attributed to pre-existing human relations ideas is that of Henry S. Dennison. The one time president of the Taylor Society has been linked to both Taylorist principles as well human relation ideals thus creating a nexus between Taylorism and human relation thought. Dennison demonstrated an activist concern both with the rationale and character of workers, and with the control and management undertaken by managers of the business enterprise.
In order to assess the validity of human relations as a benchmark for rights within the workplace, the contribution of Taylorism in comparison to human relations must be established. Taylorism and scientific management entailed to be a "complete mental revolution" and as Taylor explained, Taylorism sought to encourage managers and labourers to "take their eyes off of the division of the surplus as the important matter, and together turn their attention toward increasing the size of the surplus." This notion of management appealed to the employer as it addressed organisational problems, inefficiencies and adverse employer-employee relations. Scientific management aimed to use science and qualitative data in the selection of employees and facilitate the use of employee databases and performance reviews. Firstly, scientific management aimed to reduce inefficiency through studying the time and motions in work tasks. The object of time studies was to determine how fast a job should and could be done. Secondly, Taylor purported to introduce specific quantitative goals to individual employees in order to provide challenging time restraints and thus increasing productivity. Most importantly, Taylor sought to increase productivity through organization of behaviour.
See also
Group dynamics
People skills
Social psychology
References
Organizational theory
Systems psychology
Human resource management
Industrial and organizational psychology
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Distress (medicine)
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In medicine, distress is an aversive state in which a person is unable to completely adapt to difficult situations and their resulting effects and shows maladaptive behaviors. It can be evident in the presence of various phenomena, such as inappropriate social interaction (e.g., aggression, passivity, or withdrawal).
Distress is the opposite of eustress, a positive emotion that motivates people.
Risk factors
Stress can be created by influences such as work, school, peers or co-workers, family and death. Other influences vary by age.
People under constant distress are more likely to become sick, mentally or physically. There is a clear response association between psychological distress and major causes of mortality across the full range of distress.
Higher education has been linked to a reduction in psychological distress in both men and women, and these effects persist throughout the aging process, not just immediately after receiving education. However, this link does lessen with age. The major mechanism by which higher education plays a role on reducing stress in men is more so related to labor-market resources rather than social resources as in women.
In the clinic, distress is a patient reported outcome that has a huge impact on patient's quality of life. To assess patient distress, a Hospital Anxiety and Depression Scale (HADS) questionnaire is most commonly used. The score from the HADS questionnaire guides a clinician to recommend lifestyle modifications or further assessment for mental disorders like depression.
Management
People often find ways of dealing with distress, in both negative and positive ways. Examples of positive ways are listening to music, calming exercises, coloring, sports and similar healthy distractions. Negative ways can include but are not limited to use of drugs including alcohol, and expression of anger, which are likely to lead to complicated social interactions, thus causing increased distress.
See also
Intentional infliction of emotional distress
References
Medical terminology
Mental states
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Expressed emotion
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Expressed emotion (EE), is a measure of the family environment that is based on how the relatives of a psychiatric patient spontaneously talk about the patient. It specifically measures three to five aspects of the family environment: the most important are critical comments, hostility, emotional over-involvement, with positivity and warmth sometimes also included as indications of a low-EE environment. The psychiatric measure of expressed emotion is distinct from the general notion of communicating emotion in interpersonal relationships, and from another psychological metric known as family emotional expressiveness.
A high level of EE in the home can worsen the prognosis in patients with mental illness, such as schizophrenia and social anxiety disorder, or act as a potential risk factor for the development of psychiatric disease. Higher degrees of expressed emotion in the environment of a patient have been empirically found to be robust predictors of relapse of schizophrenia, eating disorder, and mood disorders. It has also been investigated as a contributor to the progress of unipolar depression, bipolar disorder, dementia, and diabetes. Interventions to improve outcomes include reducing contact with high-EE caregivers, and educating and supporting families so they can reduce high-EE behavior.
Various mechanisms have been proposed to explain why high EE family environments produce worse outcomes, including that:
Critical comments often misidentify certain behaviors as laziness or selfishness rather than symptoms of a mental illness.
Over-protectiveness can undermine the patient's self-reliance and ability to use their own skills to solve mental health problems.
High-EE behaviors can be a source of psychological stress, which exacerbates mental illness (the diathesis–stress model).
Typically it is determined whether a person or family has high EE or low EE through a taped interview known as the Camberwell Family Interview (CFI). Answers to questions and non-verbal cues are used to determine if someone has high expressed emotion. There is another measurement that is taken from the view of the patient, which rates the patient's perception of how their family feels about them and the disorder. An alternative measure of expressed emotion is the Five Minutes Speech Sample (FMSS), where the relatives are asked to talk about the patient for five uninterrupted minutes. Although this measure requires more training, it becomes a quicker form of assessment than the CFI.
History
A 1956 study of readmissions of schizophrenia patients in London by George Brown found that patients discharged to live with their parents or wives were more frequently readmitted than those discharged to live with siblings or non-family in lodging houses. It also found that those that lived with their mothers were more likely to be readmitted if the mothers did not work outside the home, suggesting that the duration of exposure to certain family members was related to relapse. Brown devised the five dimensions of expressed emotion to quantify the interpersonal environmental exposures of patients.
The advantage of a low-EE environment has been cited to partly explain the success of the Belgian village of Geel, where residents have for hundreds of years welcomed unrelated people with mental illness to live with them.
Janis H. Jenkins and her team conducted the first study showing that Mexican immigrants’ familial emotional responses of warmth and sympathy toward mentally ill kin in the United States contributes to a more favorable course of illness than in the case of their Euro-American counterparts.
High expressed emotion
Family members with high expressed emotion are hostile, very critical and not tolerant of the patient. They feel like they are helping by having this attitude. They not only criticize behaviors relating to the disorder but also other behaviors that are unique to the personality of the patient. High expressed emotion is more likely to cause a relapse than low expressed emotion.
The three dimensions of high EE are hostility, emotional over-involvement and critical comments.
Hostility
Hostility is a negative attitude directed at the patient because the family feels that the disorder is controllable and that the patient is choosing not to get better. Problems in the family are often blamed on the patient and the patient has trouble problem solving in the family. The family believes that the cause of many of the family's problems is the patient's mental illness, whether they are or not.
Emotional over-involvement
Emotional over-involvement reflects a set of feelings and behavior of a family member towards the patient, indicating evidence of over-protectiveness or self-sacrifice, excessive use of praise or blame, preconceptions and statements of attitude. Family members who show high emotional involvement tend to be more intrusive. Therefore, families with high emotional involvement may believe that patients cannot help themselves and that their problems are due to causes external to them, and thus high involvement will lead to strategies of taking control and doing things for the patients. In addition, patients may feel very anxious and frustrated when interacting with family caregivers with high emotional involvement due to such high intrusiveness and emotional display towards them. On the whole, families with high EE appear to be poorer communicators with their ill relative as they might talk more and listen less effectively. Emotional over-involvement demonstrates a different side compared to hostile and critical attitudes but is still similar with the negative affect that causes a relapse. The relative becomes so overbearing that the patient can no longer live with this kind of stress from pity, and falls back into their illness as a way to cope.
Critical comments
Critical comments include complaints that the patient is a burden to the family, that the patient is not following instructions, or that the patient is lazy or selfish.
Interventions
Low expressed emotion occurs when the family members are less critical or hostile, and not overly-involved. Low expressed emotion is associated with more positive outcomes for the patient. Psychoeducation on the course and associated effects of the illness, as well as behavioral interventions and communication training can help families move from high expressed emotion to low expressed emotion. However, it is believed that in the early stages of the illness, families should be allowed to grieve and be supported emotionally, and that behavioral interventions can actually increase relapse rates at this critical juncture.
High expressed emotion, by contrast, makes the patient feel trapped, out of control and dependent upon others. The patient may feel like an outsider because of the excessive attention received. Expressed emotion affects everyone in the home, raising the stress level for the family and often increasing anxiety and depression among family members. The behavior of everyone around the patient influences the course of the patient's illness. Academics suggest that movement from high to low expressed emotion is best facilitated by a family therapist, psychiatrist, or family worker, preferably one experienced in the treatment of families with a psychotic family member. Family therapists suggest that treatment is more successful with the attendance of as many household members as possible, in order to give a more complete picture of family patterns. However, the necessity of family therapy does not indicate that the illness is the fault of the family. Family therapy in this area has moved away from the notion that family communication patterns are responsible for psychosis, a notion popularized in the 1960s by family systems therapist Murray Bowen.
Validity
Some studies show that there is no link between expressed emotion and first episode psychosis, illness severity, age of onset, and illness length.
There is also literature that links EE to the course and outcome of numerous major childhood psychiatric disorders. One study showed that one component, high parental dimensions of criticism (CRIT), can be used as an index of problematic parent–child interactions.
In social anxiety disorder, it has been found parents' high level of expressed emotion (emotional overinvolvement, criticism, hostility) is strongly associated with treatment outcome in their children.
See also
Social defeat
Double Bind
References
Further reading
External links
http://www.personalityresearch.org/papers/mcdonagh.html
Emotional issues
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Sociocultural perspective
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The sociocultural perspective is a theory used in fields such as psychology and education and is used to describe awareness of circumstances surrounding individuals and how their behaviors are affected specifically by their surrounding, social and cultural factors. According to Catherine A. Sanderson (2010) “Sociocultural perspective: A perspective describing people’s behavior and mental processes as shaped in part by their social and/or cultural contact, including race, gender, and nationality.” Sociocultural perspective theory is a broad yet significant aspect in our being. It applies to every sector of our daily lives. How we communicate, understand, relate and cope with one another is partially based on this theory. Our spiritual, mental, physical, emotional, physiological being are all influenced by factors studied by sociocultural perspective theory.
Ideology
Various studies examine topics using the sociocultural perspective in order to account for variability from person to person and acknowledge that social and cultural differences affect these individuals. One example comes from the journal European Psychologist: Investigating Motivation in Context: Developing Sociocultural Perspectives by Richard A. Walker, Kimberley Pressick-kilborn, Bert M. Lancaster, and Erica J. Sainsbury (2004). Recently, however, a renewed interest in the contextual nature of motivation has come about for several reasons. First, the relatively recent influence of the ideas of Vygotsky and his followers (John-Steiner & Mahn, 1996; Greeno & The Middle School Through Applications Project, 1998) in educational psychology has led writers in the field (Goodenow, 1992; Pintrich, 1994; Anderman & Anderman, 2000) to acknowledge the importance of context and to call for its greater recognition in educational psychology, and more particularly in motivational research. As both Goodenow (1992) and Hickey (1997) note, in sociocultural theories deriving from Vygotsky, human activities, events, and actions cannot be separated from the context in which they occur so that context becomes an important issue in sociocultural research. Second, researchers concerned with learning and cognition (e.g., Greeno et al., 1998) have come to see these processes also as being situated in particular contexts. While this view, with its emphasis on the distributed nature of learning and cognition, has origins in sociocultural theories".
This theory or perspective is examined in The Modern Language Journal “A Sociocultural Perspective on Language Learning Strategies: The Role of Mediation” by Richard Donato and Dawn McCormick. According to Donato and McCormick (1994) “Sociocultural theory maintains that social interaction and cultural institutions, such as schools, classrooms, etc., have important roles to play in an individual’s cognitive growth and development.” “We believe that this perspective goes beyond current cognitive and social psychological conceptions of strategic language learning, both of which assume that language tasks and contexts are generalizable. The sociocultural perspective, on the other hand, views language learning tasks and contexts as situated activities that are continually under development (22) and that are influential upon individuals’ strategic orientations to classroom learning.”
Health factors
The sociocultural perspective is also used here in order to assess use of mental health services for immigrants: “From a sociocultural perspective, this article reviews causes of mental health service under use among Chinese immigrants and discusses practice implications. Factors explaining service under use among Chinese immigrants are multifaceted, extending across individual, family, cultural and system domains. The first of these is cultural explanation of mental illness. Cultural beliefs, regarding the cause of mental disorders greatly affect service use. The perceived causes of mental illness include moral, religious, or cosmological, physiological, psychological, social and genetic factors”. From Canadian Social Work, “A Sociocultural Perspective of Mental Health Services Use by Chinese Immigrants” by Lin Fang, (2010).
Coping
According to Asian American Journal of Psychology, "Coping with perceived racial and gender discrimination experiences among 11 Asian/Asian American female faculty at various Christian universities" have been examined in this theory. After the study was conducted the results revealed that "ten of the 11 women described experiences where they perceived being treated differently due to race and/or gender. Qualitative analyses of interview data revealed four themes related to coping: Proactive Coping, External Support, Personal Resources, and Spiritual Coping. The resulting themes are discussed in light of existing research, with an emphasis on the importance of understanding cultural and religious values to the study of coping".
Language
Another instance of the sociocultural perspective can be found in language learning literature: “By adopting a sociocultural perspective that highlights the critical role of the social context in cognitive and social development (Vygotsky, 1978), we propose that learners’ actions to facilitate or sometimes constrain their language learning cannot be fully understood without considering the situated contexts in which strategies emerge and develop, as well as the kinds of hierarchies within which studies from diverse backgrounds find themselves in U.S. classrooms (Bourdieu, 1991). From Theory Into Practice, “A Sociocultural Perspective on Second Language Learner Strategies: Focus on the Impact of Social Context.” by Eun-Young Jang and Robert T. Jimenez, 2011.
References
-Kim, C. L., Hall, M., Anderson, T. L., & Willingham, M. M. (2011). Coping with discrimination in academia: Asian-American and Christian perspectives. Asian American Journal of Psychology, 2(4), 291-305.
-Jarrett, C. (2008). Foundations of sand?. The Psychologist, 21(9), 756-759.
-European Psychologist, Vol 9(4), Dec, 2004. Special Section: Motivation in Real-Life, Dynamic, and Interactive Learning Environments. pp. 245–256
-Modern Language Journal, Vol 78(4), Win, 1994. Special issue: Sociocultural theory and second language learning. pp. 453–464.
-Canadian Social Work: “A Sociocultural Perspective of Mental Health Services Use by Chinese Immigrants” by Lin Fang, Autumn 2010, Vol. 12 Issue 1, p152-160, 9p
-Theory Into Practice. A Sociocultural Perspective on Second Language Learner Strategies: Focus on the Impact of Social Context. Eun-Young Jang and Robert T. Jimenez 2011, Vol. 50 Issue 2, p141-148. 8p.
Footnotes
General references
Kim, C. L., Hall, M., Anderson, T. L., & Willingham, M. M. (2011). Coping with discrimination in academia: Asian-American and Christian perspectives. Asian American Journal of Psychology, 2(4), 291-305.
Jarrett, C. (2008). Foundations of sand?. The Psychologist, 21(9), 756-759.
European Psychologist, Vol 9(4), Dec, 2004. Special Section: Motivation in Real-Life, Dynamic, and Interactive Learning Environments. pp. 245–256
Modern Language Journal, Vol 78(4), Win, 1994. Special issue: Sociocultural theory and second language learning. pp. 453–464.
Canadian Social Work: “A Sociocultural Perspective of Mental Health Services Use by Chinese Immigrants” by Lin Fang, Autumn 2010, Vol. 12 Issue 1, p152-160, 9p
Theory Into Practice. A Sociocultural Perspective on Second Language Learner Strategies: Focus on the Impact of Social Context. Eun-Young Jang and Robert T. Jimenez 2011, Vol. 50 Issue 2, p141-148. 8p.
Psychological theories
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Biology of depression
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Scientific studies have found that different brain areas show altered activity in humans with major depressive disorder (MDD), and this has encouraged advocates of various theories that seek to identify a biochemical origin of the disease, as opposed to theories that emphasize psychological or situational causes. Factors spanning these causative groups include nutritional deficiencies in magnesium, vitamin D, and tryptophan with situational origin but biological impact. Several theories concerning the biologically based cause of depression have been suggested over the years, including theories revolving around monoamine neurotransmitters, neuroplasticity, neurogenesis, inflammation and the circadian rhythm. Physical illnesses, including hypothyroidism and mitochondrial disease, can also trigger depressive symptoms.
Neural circuits implicated in depression include those involved in the generation and regulation of emotion, as well as in reward. Abnormalities are commonly found in the lateral prefrontal cortex whose putative function is generally considered to involve regulation of emotion. Regions involved in the generation of emotion and reward such as the amygdala, anterior cingulate cortex (ACC), orbitofrontal cortex (OFC), and striatum are frequently implicated as well. These regions are innervated by a monoaminergic nuclei, and tentative evidence suggests a potential role for abnormal monoaminergic activity.
Genetic factors
Difficulty of gene studies
Historically, candidate gene studies have been a major focus of study. However, as the number of genes reduces the likelihood of choosing a correct candidate gene, Type I errors (false positives) are highly likely. Candidate genes studies frequently possess a number of flaws, including frequent genotyping errors and being statistically underpowered. These effects are compounded by the usual assessment of genes without regard for gene-gene interactions. These limitations are reflected in the fact that no candidate gene has reached genome-wide significance.
Gene candidates
5-HTTLPR
The 5-HTTLPR, or serotonin transporter promoter gene's short allele, has been associated with increased risk of depression; since the 1990s, however, results have been inconsistent. Other genes that have been linked to a gene–environment interaction include CRHR1, FKBP5 and BDNF, the first two of which are related to the stress reaction of the HPA axis, and the latter of which is involved in neurogenesis. Candidate gene analysis of 5-HTTLPR on depression was inconclusive on its effect, either alone or in combination with life stress.
A 2003 study proposed that a gene-environment interaction (GxE) may explain why life stress is a predictor for depressive episodes in some individuals, but not in others, depending on an allelic variation of the serotonin-transporter-linked promoter region (5-HTTLPR). This hypothesis was widely discussed in both the scientific literature and popular media, where it was dubbed the "Orchid gene", but has conclusively failed to replicate in much larger samples, and the observed effect sizes in earlier work are not consistent with the observed polygenicity of depression.
BDNF
BDNF polymorphisms have also been hypothesized to have a genetic influence, but early findings and research failed to replicate in larger samples, and the effect sizes found by earlier estimates are inconsistent with the observed polygenicity of depression.
SIRT1 and LHPP
A 2015 GWAS study in Han Chinese women positively identified two variants in intronic regions near SIRT1 and LHPP with a genome-wide significant association.
Norepinephrine transporter polymorphisms
Attempts to find a correlation between norepinephrine transporter polymorphisms and depression have yielded negative results.
One review identified multiple frequently studied candidate genes. The genes encoding for the 5-HTT and 5-HT2A receptor were inconsistently associated with depression and treatment response. Mixed results were found for brain-derived neurotrophic factor (BDNF) Val66Met polymorphisms. Polymorphisms in the tryptophan hydroxylase gene was found to be tentatively associated with suicidal behavior. A meta analysis of 182 case controlled genetic studies published in 2008 found Apolipoprotein E epsilon 2 to be protective, and GNB3 825T, MTHFR 677T, SLC6A4 44bp insertion or deletions, and SLC6A3 40 bpVNTR 9/10 genotype to confer risk.
Circadian rhythm
Depression may be related to abnormalities in the circadian rhythm, or biological clock.
A well synchronized circadian rhythm is critical for maintaining optimal health. Adverse changes and alterations in the circadian rhythm have been associated with various neurological disorders and mood disorders including depression.
Sleep
Sleep disturbance is the most prominent symptom in depressive patients. Studies about sleep electroencephalograms have shown characteristic changes in depression such as reductions in non-rapid eye movement sleep production, disruptions of sleep continuity and disinhibition of rapid eye movement (REM) sleep. Rapid eye movement (REM) sleep—the stage in which dreaming occurs—may be quick to arrive and intense in depressed people. REM sleep depends on decreased serotonin levels in the brain stem, and is impaired by compounds, such as antidepressants, that increase serotonergic tone in brain stem structures. Overall, the serotonergic system is least active during sleep and most active during wakefulness. Prolonged wakefulness due to sleep deprivation activates serotonergic neurons, leading to processes similar to the therapeutic effect of antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs). Depressed individuals can exhibit a significant lift in mood after a night of sleep deprivation. SSRIs may directly depend on the increase of central serotonergic neurotransmission for their therapeutic effect, the same system that impacts cycles of sleep and wakefulness.
Light therapy
Research on the effects of light therapy on seasonal affective disorder suggests that light deprivation is related to decreased activity in the serotonergic system and to abnormalities in the sleep cycle, particularly insomnia. Exposure to light also targets the serotonergic system, providing more support for the important role this system may play in depression. Sleep deprivation and light therapy both target the same brain neurotransmitter system and brain areas as antidepressant drugs, and are now used clinically to treat depression. Light therapy, sleep deprivation and sleep time displacement (sleep phase advance therapy) are being used in combination quickly to interrupt a deep depression in people who are hospitalized for MDD (major depressive disorder).
Increased and decreased sleep length appears to be a risk factor for depression. People with MDD sometimes show diurnal and seasonal variation of symptom severity, even in non-seasonal depression. Diurnal mood improvement was associated with activity of dorsal neural networks. Increased mean core temperature was also observed. One hypothesis proposed that depression was a result of a phase shift.
Daytime light exposure correlates with decreased serotonin transporter activity, which may underlie the seasonality of some depression.
Monoamines
Monoamines are neurotransmitters that include serotonin, dopamine, norepinephrine, and epinephrine.
Monoamine hypothesis of depression
Many antidepressant drugs acutely increase synaptic levels of the monoamine neurotransmitter, serotonin, but they may also enhance the levels of norepinephrine and dopamine. The observation of this efficacy led to the monoamine hypothesis of depression, which postulates that the deficit of certain neurotransmitters is responsible for depression, and even that certain neurotransmitters are linked to specific symptoms. Normal serotonin levels have been linked to mood and behaviour regulation, sleep, and digestion; norepinephrine to the fight-or-flight response; and dopamine to movement, pleasure, and motivation. Some have also proposed the relationship between monoamines and phenotypes such as serotonin in sleep and suicide, norepinephrine in dysphoria, fatigue, apathy, cognitive dysfunction, and dopamine in loss of motivation and psychomotor symptoms. The main limitation for the monoamine hypothesis of depression is the therapeutic lag between initiation of antidepressant treatment and perceived improvement of symptoms. One explanation for this therapeutic lag is that the initial increase in synaptic serotonin is only temporary, as firing of serotonergic neurons in the dorsal raphe adapt via the activity of 5-HT1A autoreceptors. The therapeutic effect of antidepressants is thought to arise from autoreceptor desensitization over a period of time, eventually elevating firing of serotonergic neurons.
Serotonin
The serotonin "chemical imbalance" theory of depression, proposed in the 1960s, is not supported by the available scientific evidence. SSRIs alter the balance of serotonin inside and outside of neurons: their clinical antidepressant effect (which is robust in severe depression) is likely due to more complex changes in neuronal functioning which occur as a downstream consequence of this.
Initial studies of serotonin in depression examined peripheral measures such as the serotonin metabolite 5-Hydroxyindoleacetic acid (5-HIAA) and platelet binding. The results were generally inconsistent, and may not generalize to the central nervous system. However evidence from receptor binding studies and pharmacological challenges provide some evidence for dysfunction of serotonin neurotransmission in depression. Serotonin may indirectly influence mood by altering emotional processing biases that are seen at both the cognitive/behavioral and neural level. Pharmacologically reducing serotonin synthesis, and pharmacologically enhancing synaptic serotonin can produce and attenuate negative affective biases, respectively. These emotional processing biases may explain the therapeutic gap.
Dopamine
While various abnormalities have been observed in dopaminergic systems, results have been inconsistent. People with MDD have an increased reward response to dextroamphetamine compared to controls, and it has been suggested that this results from hypersensitivity of dopaminergic pathways due to natural hypoactivity. While polymorphisms of the D4 and D3 receptor have been implicated in depression, associations have not been consistently replicated. Similar inconsistency has been found in postmortem studies, but various dopamine receptor agonists show promise in treating MDD. There is some evidence that there is decreased nigrostriatal pathway activity in people with melancholic depression (psychomotor retardation). Further supporting the role of dopamine in depression is the consistent finding of decreased cerebrospinal fluid and jugular metabolites of dopamine, as well as post mortem findings of altered dopamine receptor D3 and dopamine transporter expression. Studies in rodents have supported a potential mechanism involving stress-induced dysfunction of dopaminergic systems.
Catecholamines
A number of lines of evidence indicative of decreased adrenergic activity in depression have been reported. Findings include the decreased activity of tyrosine hydroxylase, decreased size of the locus coeruleus, increased α2 adrenergic receptor density, and decreased α1 adrenergic receptor density. Furthermore, norepinephrine transporter knockout in mice models increases their tolerance to stress, implicating norepinephrine in depression.
One method used to study the role of monoamines is monoamine depletion. Depletion of tryptophan (the precursor of serotonin), tyrosine and phenylalanine (precursors to dopamine) does result in decreased mood in those with a predisposition to depression, but not in persons lacking the predisposition. On the other hand, inhibition of dopamine and norepinephrine synthesis with alpha-methyl-para-tyrosine does not consistently result in decreased mood.
Monoamine oxidase
An offshoot of the monoamine hypothesis suggests that monoamine oxidase A (MAO-A), an enzyme which metabolizes monoamines, may be overly active in depressed people. This would, in turn, cause the lowered levels of monoamines. This hypothesis received support from a PET study, which found significantly elevated activity of MAO-A in the brain of some depressed people. In genetic studies, the alterations of MAO-A-related genes have not been consistently associated with depression. Contrary to the assumptions of the monoamine hypothesis, lowered but not heightened activity of MAO-A was associated with depressive symptoms in adolescents. This association was observed only in maltreated youth, indicating that both biological (MAO genes) and psychological (maltreatment) factors are important in the development of depressive disorders. In addition, some evidence indicates that disrupted information processing within neural networks, rather than changes in chemical balance, might underlie depression.
Limitations
Since the 1990s, research has uncovered multiple limitations of the monoamine hypothesis, and its inadequacy has been criticized within the psychiatric community. For one thing, serotonin system dysfunction cannot be the sole cause of depression. Not all patients treated with antidepressants show improvements despite the usually rapid increase in synaptic serotonin. If significant mood improvements do occur, this is often not for at least two to four weeks. One possible explanation for this lag is that the neurotransmitter activity enhancement is the result of auto receptor desensitization, which can take weeks. Intensive investigation has failed to find convincing evidence of a primary dysfunction of a specific monoamine system in people with MDD. The antidepressants that do not act through the monoamine system, such as tianeptine and opipramol, have been known for a long time. There have also been inconsistent findings with regard to levels of serum 5-HIAA, a metabolite of serotonin. Experiments with pharmacological agents that cause depletion of monoamines have shown that this depletion does not cause depression in healthy people. Another problem that presents is that drugs that deplete monoamines may actually have antidepressants properties. Further, some have argued that depression may be marked by a hyperserotonergic state. Already limited, the monoamine hypothesis has been further oversimplified when presented to the general public.
Receptor binding
As of 2012, efforts to determine differences in neurotransmitter receptor expression or for function in the brains of people with MDD using positron emission tomography (PET) had shown inconsistent results. Using the PET imaging technology and reagents available as of 2012, it appeared that the D1 receptor may be underexpressed in the striatum of people with MDD. 5-HT1A receptor binding literature is inconsistent; however, it leans towards a general decrease in the mesiotemporal cortex. 5-HT2A receptor binding appears to be dysregulated in people with MDD. Results from studies on 5-HTT binding are variable, but tend to indicate higher levels in people with MDD. Results with D2/D3 receptor binding studies are too inconsistent to draw any conclusions. Evidence supports increased MAO activity in people with MDD, and it may even be a trait marker (not changed by response to treatment). Muscarinic receptor binding appears to be increased in depression, and, given ligand binding dynamics, suggests increased cholinergic activity.
Four meta analyses on receptor binding in depression have been performed, two on serotonin transporter (5-HTT), one on 5-HT1A, and another on dopamine transporter (DAT). One meta analysis on 5-HTT reported that binding was reduced in the midbrain and amygdala, with the former correlating with greater age, and the latter correlating with depression severity. Another meta-analysis on 5-HTT including both post-mortem and in vivo receptor binding studies reported that while in vivo studies found reduced 5-HTT in the striatum, amygdala and midbrain, post mortem studies found no significant associations. 5-HT1A was found to be reduced in the anterior cingulate cortex, mesiotemporal lobe, insula, and hippocampus, but not in the amygdala or occipital lobe. The most commonly used 5-HT1A ligands are not displaced by endogenous serotonin, indicating that receptor density or affinity is reduced. Dopamine transporter binding is not changed in depression.
Emotional processing and neural circuits
Emotional bias
People with MDD show a number of biases in emotional processing, such as a tendency to rate happy faces more negatively, and a tendency to allocate more attentional resources to sad expressions. Depressed people also have impaired recognition of happy, angry, disgusted, fearful and surprised, but not sad faces. Functional neuroimaging has demonstrated hyperactivity of various brain regions in response to negative emotional stimuli, and hypoactivity in response to positive stimuli. One meta analysis reported that depressed subjects showed decreased activity in the left dorsolateral prefrontal cortex and increased activity in the amygdala in response to negative stimuli. Another meta analysis reported elevated hippocampus and thalamus activity in a subgroup of depressed subjects who were medication naive, not elderly, and had no comorbidities. The therapeutic lag of antidepressants has been suggested to be a result of antidepressants modifying emotional processing leading to mood changes. This is supported by the observation that both acute and subchronic SSRI administration increases response to positive faces. Antidepressant treatment appears to reverse mood congruent biases in limbic, prefrontal, and fusiform areas. dlPFC response is enhanced and amygdala response is attenuated during processing of negative emotions, the former of which is thought to reflect increased top down regulation. The fusiform gyrus and other visual processing areas respond more strongly to positive stimuli with antidepressant treatment, which is thought to reflect a positive processing bias. These effects do not appear to be unique to serotonergic or noradrenergic antidepressants, but also occur in other forms of treatment such as deep brain stimulation.
Neural circuits
One meta analysis of functional neuroimaging in depression observed a pattern of abnormal neural activity hypothesized to reflect an emotional processing bias. Relative to controls, people with MDD showed hyperactivity of circuits in the salience network (SN), composed of the pulvinar nuclei, the insula, and the dorsal anterior cingulate cortex (dACC), as well as decreased activity in regulatory circuits composed of the striatum and dlPFC.
A neuroanatomical model called the limbic-cortical model has been proposed to explain early biological findings in depression. The model attempts to relate specific symptoms of depression to neurological abnormalities. Elevated resting amygdala activity was proposed to underlie rumination, as stimulation of the amygdala has been reported to be associated with the intrusive recall of negative memories. The ACC was divided into pregenual (pgACC) and subgenual regions (sgACC), with the former being electrophysiologically associated with fear, and the latter being metabolically implicated in sadness in healthy subjects. Hyperactivity of the lateral orbitofrontal and insular regions, along with abnormalities in lateral prefrontal regions was suggested to underlie maladaptive emotional responses, given the regions roles in reward learning. This model and another termed "the cortical striatal model", which focused more on abnormalities in the cortico-basal ganglia-thalamo-cortical loop, have been supported by recent literature. Reduced striatal activity, elevated OFC activity, and elevated sgACC activity were all findings consistent with the proposed models. However, amygdala activity was reported to be decreased, contrary to the limbic-cortical model. Furthermore, only lateral prefrontal regions were modulated by treatment, indicating that prefrontal areas are state markers (i.e., dependent upon mood), while subcortical abnormalities are trait markers (i.e., reflect a susceptibility).
Reward
While depression severity as a whole is not correlated with a blunted neural response to reward, anhedonia is directly correlated to reduced activity in the reward system. The study of reward in depression is limited by heterogeneity in the definition and conceptualizations of reward and anhedonia. Anhedonia is broadly defined as a reduced ability to feel pleasure, but questionnaires and clinical assessments rarely distinguish between motivational "wanting" and consummatory "liking". While a number of studies suggest that depressed subjects rate positive stimuli less positively and as less arousing, a number of studies fail to find a difference. Furthermore, response to natural rewards such as sucrose does not appear to be attenuated. General affective blunting may explain "anhedonic" symptoms in depression, as meta analysis of both positive and negative stimuli reveal reduced rating of intensity. As anhedonia is a prominent symptom of depression, direct comparison of depressed with healthy subjects reveals increased activation of the subgenual anterior cingulate cortex (sgACC), and reduced activation of the ventral striatum, and in particular the nucleus accumbens (NAcc) in response to positive stimuli. Although the finding of reduced NAcc activity during reward paradigms is fairly consistent, the NAcc is made up of a functionally diverse range of neurons, and reduced blood-oxygen-level dependent (BOLD) signal in this region could indicate a variety of things including reduced afferent activity or reduced inhibitory output. Nevertheless, these regions are important in reward processing, and dysfunction of them in depression is thought to underlie anhedonia. Residual anhedonia that is not well targeted by serotonergic antidepressants is hypothesized to result from inhibition of dopamine release by activation of 5-HT2C receptors in the striatum. The response to reward in the medial orbitofrontal cortex (OFC) is attenuated in depression, while lateral OFC response is enhanced to punishment. The lateral OFC shows sustained response to absence of reward or punishment, and it is thought to be necessary for modifying behavior in response to changing contingencies. Hypersensitivity in the lOFC may lead to depression by producing a similar effect to learned helplessness in animals.
Elevated response in the sgACC is a consistent finding in neuroimaging studies using a number of paradigms including reward related tasks. Treatment is also associated with attenuated activity in the sgACC, and inhibition of neurons in the rodent homologue of the sgACC, the infralimbic cortex (IL), produces an antidepressant effect. Hyperactivity of the sgACC has been hypothesized to lead to depression via attenuating the somatic response to reward or positive stimuli. Contrary to studies of functional magnetic resonance imaging response in the sgACC during tasks, resting metabolism is reduced in the sgACC. However, this is only apparent when correcting for the prominent reduction in sgACC volume associated with depression; structural abnormalities are evident at a cellular level, as neuropathological studies report reduced sgACC cell markers. The model of depression proposed from these findings by Drevets et al. suggests that reduced sgACC activity results in enhanced sympathetic nervous system activity and blunted HPA axis feedback. Activity in the sgACC may also not be causal in depression, as the authors of one review that examined neuroimaging in depressed subjects during emotional regulation hypothesized that the pattern of elevated sgACC activity reflected increased need to modulate automatic emotional responses in depression. More extensive sgACC and general prefrontal recruitment during positive emotional processing was associated with blunted subcortical response to positive emotions, and subject anhedonia. This was interpreted by the authors to reflect a downregulation of positive emotions by the excessive recruitment of the prefrontal cortex.
Neuroanatomy
While a number of neuroimaging findings are consistently reported in people with major depressive disorder, the heterogeneity of depressed populations presents difficulties interpreting these findings. For example, averaging across populations may hide certain subgroup related findings; while reduced dlPFC activity is reported in depression, a subgroup may present with elevated dlPFC activity. Averaging may also yield statistically significant findings, such as reduced hippocampal volumes, that are actually present in a subgroup of subjects. Due to these issues and others, including the longitudinal consistency of depression, most neural models are likely inapplicable to all depression.
Structural neuroimaging
Meta analyses performed using seed-based d mapping have reported grey matter reductions in a number of frontal regions. One meta analysis of early onset general depression reported grey matter reductions in the bilateral anterior cingulate cortex (ACC) and dorsomedial prefrontal cortex (dmPFC). One meta analysis on first episode depression observed distinct patterns of grey matter reductions in medication free, and combined populations; medication free depression was associated with reductions in the right dorsolateral prefrontal cortex, right amygdala, and right inferior temporal gyrus; analysis on a combination of medication free and medicated depression found reductions in the left insula, right supplementary motor area, and right middle temporal gyrus. Another review distinguishing medicated and medication free populations, albeit not restricted to people with their first episode of MDD, found reductions in the combined population in the bilateral superior, right middle, and left inferior frontal gyrus, along with the bilateral parahippocampus. Increases in thalamic and ACC grey matter was reported in the medication free and medicated populations respectively. A meta analysis performed using "activation likelihood estimate" reported reductions in the paracingulate cortex, dACC and amygdala.
Using statistical parametric mapping, one meta analysis replicated previous findings of reduced grey matter in the ACC, medial prefrontal cortex, inferior frontal gyrus, hippocampus and thalamus; however reductions in the OFC and ventromedial prefrontal cortex grey matter were also reported.
Two studies on depression from the ENIGMA consortium have been published, one on cortical thickness, and the other on subcortical volume. Reduced cortical thickness was reported in the bilateral OFC, ACC, insula, middle temporal gyri, fusiform gyri, and posterior cingulate cortices, while surface area deficits were found in medial occipital, inferior parietal, orbitofrontal and precentral regions. Subcortical abnormalities, including reductions in hippocampus and amygdala volumes, which were especially pronounced in early onset depression.
Multiple meta analysis have been performed on studies assessing white matter integrity using fractional anisotropy (FA). Reduced FA has been reported in the corpus callosum (CC) in both first episode medication naive, and general major depressive populations. The extent of CC reductions differs from study to study. People with MDD who have not taken antidepressants before have been reported to have reductions only in the body of the CC and only in the genu of the CC. On the other hand, general MDD samples have been reported to have reductions in the body of the CC, the body and genu of the CC, and only the genu of the CC. Reductions of FA have also been reported in the anterior limb of the internal capsule (ALIC) and superior longitudinal fasciculus.
Functional neuroimaging
Studies of resting state activity have utilized a number of indicators of resting state activity, including regional homogeneity (ReHO), amplitude of low frequency fluctuations (ALFF), fractional amplitude of low frequency fluctuations (fALFF), arterial spin labeling (ASL), and positron emission tomography (PET) measures of regional cerebral blood flow or metabolism.
Studies using ALFF and fALFF have reported elevations in ACC activity, with the former primarily reporting more ventral findings, and the latter more dorsal findings. A conjunction analysis of ALFF and CBF studies converged on the left insula, with previously untreated people having increased insula activity. Elevated caudate CBF was also reported A meta analysis combining multiple indicators of resting activity reported elevated anterior cingulate, striatal, and thalamic activity and reduced left insula, post-central gyrus and fusiform gyrus activity. An activation likelihood estimate (ALE) meta analysis of PET/SPECT resting state studies reported reduced activity in the left insula, pregenual and dorsal anterior cingulate cortex and elevated activity in the thalamus, caudate, anterior hippocampus and amygdala. Compared to the ALE meta analysis of PET/SPECT studies, a study using multi-kernel density analysis reported hyperactivity only in the pulvinar nuclei of the thalamus.
Brain regions
Research on the brains of people with MDD usually shows disturbed patterns of interaction between multiple parts of the brain. Several areas of the brain are implicated in studies seeking to more fully understand the biology of depression:
Subgenual cingulate
Studies have shown that Brodmann area 25, also known as subgenual cingulate, is metabolically overactive in treatment-resistant depression. This region is extremely rich in serotonin transporters and is considered as a governor for a vast network involving areas like hypothalamus and brain stem, which influences changes in appetite and sleep; the amygdala and insula, which affect the mood and anxiety; the hippocampus, which plays an important role in memory formation; and some parts of the frontal cortex responsible for self-esteem. Thus disturbances in this area or a smaller than normal size of this area contributes to depression. Deep brain stimulation has been targeted to this region in order to reduce its activity in people with treatment resistant depression.
Prefrontal cortex
One review reported hypoactivity in the prefrontal cortex of those with depression compared to controls. The prefrontal cortex is involved in emotional processing and regulation, and dysfunction of this process may be involved in the etiology of depression. One study on antidepressant treatment found an increase in PFC activity in response to administration of antidepressants. One meta analysis published in 2012 found that areas of the prefrontal cortex were hypoactive in response to negative stimuli in people with MDD. One study suggested that areas of the prefrontal cortex are part of a network of regions including dorsal and pregenual cingulate, bilateral middle frontal gyrus, insula and superior temporal gyrus that appear to be hypoactive in people with MDD. However the authors cautioned that the exclusion criteria, lack of consistency and small samples limit results.
Amygdala
The amygdala, a structure involved in emotional processing appears to be hyperactive in those with major depressive disorder. The amygdala in unmedicated depressed persons tended to be smaller than in those that were medicated, however aggregate data shows no difference between depressed and healthy persons. During emotional processing tasks right amygdala is more active than the left, however there is no differences during cognitive tasks, and at rest only the left amygdala appears to be more hyperactive. One study, however, found no difference in amygdala activity during emotional processing tasks.
Hippocampus
Atrophy of the hippocampus has been observed during depression, consistent with animal models of stress and neurogenesis.
Stress can cause depression and depression-like symptoms through monoaminergic changes in several key brain regions as well as suppression in hippocampal neurogenesis. This leads to alteration in emotion and cognition related brain regions as well as HPA axis dysfunction. Through the dysfunction, the effects of stress can be exacerbated including its effects on 5-HT. Furthermore, some of these effects are reversed by antidepressant action, which may act by increasing hippocampal neurogenesis. This leads to a restoration in HPA activity and stress reactivity, thus restoring the deleterious effects induced by stress on 5-HT.
The hypothalamic-pituitary-adrenal axis is a chain of endocrine structures that are activated during the body's response to stressors of various sorts. The HPA axis involves three structure, the hypothalamus which release CRH that stimulates the pituitary gland to release ACTH which stimulates the adrenal glands to release cortisol. Cortisol has a negative feedback effect on the pituitary gland and hypothalamus. In people with MDD this often shows increased activation in depressed people, but the mechanism behind this is not yet known. Increased basal cortisol levels and abnormal response to dexamethasone challenges have been observed in people with MDD. Early life stress has been hypothesized as a potential cause of HPA dysfunction. HPA axis regulation may be examined through a dexamethasone suppression tests, which tests the feedback mechanisms. Non-suppression of dexamethasone is a common finding in depression, but is not consistent enough to be used as a diagnostic tool. HPA axis changes may be responsible for some of the changes such as decreased bone mineral density and increased weight found in people with MDD. One drug, ketoconazole, currently under development has shown promise in treating MDD.
Hippocampal Neurogenesis
Reduced hippocampal neurogenesis leads to a reduction in hippocampal volume. A genetically smaller hippocampus has been linked to a reduced ability to process psychological trauma and external stress, and subsequent predisposition to psychological illness. Depression without familial risk or childhood trauma has been linked to a normal hippocampal volume but localised dysfunction.
Animal models
A number of animal models exist for depression, but they are limited in that depression involves primarily subjective emotional changes. However, some of these changes are reflected in physiology and behavior, the latter of which is the target of many animal models. These models are generally assessed according to four facets of validity; the reflection of the core symptoms in the model; the predictive validity of the model; the validity of the model with regard to human characteristics of etiology; and the biological plausibility.
Different models for inducing depressive behaviors have been utilized; neuroanatomical manipulations such as olfactory bulbectomy or circuit specific manipulations with optogenetics; genetic models such as 5-HT1A knockout or selectively bred animals; models involving environmental manipulation associated with depression in humans, including chronic mild stress, early life stress and learned helplessness. The validity of these models in producing depressive behaviors may be assessed with a number of behavioral tests. Anhedonia and motivational deficits may, for example, be assessed via examining an animal's level of engagement with rewarding stimuli such as sucrose or intracranial self-stimulation. Anxious and irritable symptoms may be assessed with exploratory behavior in the presence of a stressful or novelty environment, such as the open field test, novelty suppressed feeding, or the elevated plus-maze. Fatigue, psychomotor poverty, and agitation may be assessed with locomotor activity, grooming activity, and open field tests.
Animal models possess a number of limitations due to the nature of depression. Some core symptoms of depression, such as rumination, low self-esteem, guilt, and depressed mood cannot be assessed in animals as they require subjective reporting. From an evolutionary standpoint, the behavior correlates of defeats of loss are thought to be an adaptive response to prevent further loss. Therefore, attempts to model depression that seeks to induce defeat or despair may actually reflect adaption and not disease. Furthermore, while depression and anxiety are frequently comorbid, dissociation of the two in animal models is difficult to achieve. Pharmacological assessment of validity is frequently disconnected from clinical pharmacotherapeutics in that most screening tests assess acute effects, while antidepressants normally take a few weeks to work in humans.
Neurocircuits
Regions involved in reward are common targets of manipulation in animal models of depression, including the nucleus accumbens (NAc), ventral tegmental area (VTA), ventral pallidum (VP), lateral habenula (LHb) and medial prefrontal cortex (mPFC). Tentative fMRI studies in humans demonstrate elevated LHb activity in depression. The lateral habenula projects to the RMTg to drive inhibition of dopamine neurons in the VTA during omission of reward. In animal models of depression, elevated activity has been reported in LHb neurons that project to the ventral tegmental area (ostensibly reducing dopamine release). The LHb also projects to aversion reactive mPFC neurons, which may provide an indirect mechanism for producing depressive behaviors. Learned helplessness induced potentiation of LHb synapses are reversed by antidepressant treatment, providing predictive validity. A number of inputs to the LHb have been implicated in producing depressive behaviors. Silencing GABAergic projections from the NAc to the LHb reduces conditioned place preference induced in social aggression, and activation of these terminals induces CPP. Ventral pallidum firing is also elevated by stress induced depression, an effect that is pharmacologically valid, and silencing of these neurons alleviates behavioral correlates of depression. Tentative in vivo evidence from people with MDD suggests abnormalities in dopamine signalling. This led to early studies investigating VTA activity and manipulations in animal models of depression. Massive destruction of VTA neurons enhances depressive behaviors, while VTA neurons reduce firing in response to chronic stress. However, more recent specific manipulations of the VTA produce varying results, with the specific animal model, duration of VTA manipulation, method of VTA manipulation, and subregion of VTA manipulation all potentially leading to differential outcomes. Stress and social defeat induced depressive symptoms, including anhedonia, are associated with potentiation of excitatory inputs to dopamine D2 receptor-expressing medium spiny neurons (D2-MSNs) and depression of excitatory inputs to dopamine D1 receptor-expressing medium spiny neurons (D1-MSNs). Optogenetic excitation of D1-MSNs alleviates depressive symptoms and is rewarding, while the same with D2-MSNs enhances depressive symptoms. Excitation of glutaminergic inputs from the ventral hippocampus reduces social interactions, and enhancing these projections produces susceptibility to stress-induced depression. Manipulations of different regions of the mPFC can produce and attenuate depressive behaviors. For example, inhibiting mPFC neurons specifically in the intralimbic cortex attenuates depressive behaviors. The conflicting findings associated with mPFC stimulation, when compared to the relatively specific findings in the infralimbic cortex, suggest that the prelimbic cortex and infralimbic cortex may mediate opposing effects. mPFC projections to the raphe nuclei are largely GABAergic and inhibit the firing of serotonergic neurons. Specific activation of these regions reduce immobility in the forced swim test but do not affect open field or forced swim behavior. Inhibition of the raphe shifts the behavioral phenotype of uncontrolled stress to a phenotype closer to that of controlled stress.
Altered neuroplasticity
Recent studies have called attention to the role of altered neuroplasticity in depression. A review found a convergence of three phenomena:
Chronic stress reduces synaptic and dendritic plasticity
Depressed subjects show evidence of impaired neuroplasticity (e.g. shortening and reduced complexity of dendritic trees)
Anti-depressant medications may enhance neuroplasticity at both a molecular and dendritic level.
The conclusion is that disrupted neuroplasticity is an underlying feature of depression, and is reversed by antidepressants.
Blood levels of BDNF in people with MDD increase significantly with antidepressant treatment and correlate with decrease in symptoms. Post mortem studies and rat models demonstrate decreased neuronal density in the prefrontal cortex in people with MDD. Rat models demonstrate histological changes consistent with MRI findings in humans, however studies on neurogenesis in humans are limited. Antidepressants appear to reverse the changes in neurogenesis in both animal models and humans.
Inflammation
Various reviews have found that general inflammation may play a role in depression. One meta analysis of cytokines in people with MDD found increased levels of pro-inflammatory IL-6 and TNF-α levels relative to controls. The first theories came about when it was noticed that interferon therapy caused depression in a large number of people receiving it. Meta analysis on cytokine levels in people with MDD have demonstrated increased levels of IL-1, IL-6, C-reactive protein, but not IL-10. Increased numbers of T-Cells presenting activation markers, levels of neopterin, IFN-γ, sTNFR, and IL-2 receptors have been observed in depression. Various sources of inflammation in depressive illness have been hypothesized and include trauma, sleep problems, diet, smoking and obesity. Cytokines, by manipulating neurotransmitters, are involved in the generation of sickness behavior, which shares some overlap with the symptoms of depression. Neurotransmitters hypothesized to be affected include dopamine and serotonin, which are common targets for antidepressant drugs. Induction of indoleamine 2,3-dioxygenase by cytokines has been proposed as a mechanism by which immune dysfunction causes depression. One review found normalization of cytokine levels after successful treatment of depression. A meta analysis published in 2014 found the use of anti-inflammatory drugs such as NSAIDs and investigational cytokine inhibitors reduced depressive symptoms. Exercise can act as a stressor, decreasing the levels of IL-6 and TNF-α and increasing those of IL-10, an anti-inflammatory cytokine.
Inflammation is also intimately linked with metabolic processes in humans. For example, low levels of vitamin D have been associated with greater risk for depression. The role of metabolic biomarkers in depression is an active research area. Recent work has explored the potential relationship between plasma sterols and depressive symptom severity.
Oxidative stress
A marker of DNA oxidation, 8-Oxo-2'-deoxyguanosine, has been found to be increased in both the plasma and urine of people with MDD. This along with the finding of increased F2-isoprostanes levels found in blood, urine and cerebrospinal fluid indicate increased damage to lipids and DNA in people with MDD. Studies with 8-Oxo-2'-deoxyguanosine varied by methods of measurement and type of depression, but F2-isoprostane level was consistent across depression types. Authors suggested lifestyle factors, dysregulation of the HPA axis, immune system and autonomics nervous system as possible causes. Another meta-analysis found similar results with regards to oxidative damage products as well as decreased oxidative capacity. Oxidative DNA damage may play a role in MDD.
Mitochondrial dysfunction
Increased markers of oxidative stress relative to controls have been found in people with MDD. These markers include high levels of RNS and ROS which have been shown to influence chronic inflammation, damaging the electron transport chain and biochemical cascades in mitochondria. This lowers the activity of enzymes in the respiratory chain resulting in mitochondrial dysfunction. The brain is a highly energy-consuming and has little capacity to store glucose as glycogen and so depends greatly on mitochondria. Mitochondrial dysfunction has been linked to the dampened neuroplasticity observed in depressed brains.
Large-scale brain network theory
Instead of studying one brain region, studying large scale brain networks is another approach to understanding psychiatric and neurological disorders, supported by recent research that has shown that multiple brain regions are involved in these disorders. Understanding the disruptions in these networks may provide important insights into interventions for treating these disorders. Recent work suggests that at least three large-scale brain networks are important in psychopathology:
Central executive network
The central executive network is made up of fronto-parietal regions, including dorsolateral prefrontal cortex and lateral posterior parietal cortex. This network is involved in high level cognitive functions such as maintaining and using information in working memory, problem solving, and decision making. Deficiencies in this network are common in most major psychiatric and neurological disorders, including depression. Because this network is crucial for everyday life activities, those who are depressed can show impairment in basic activities like test taking and being decisive.
Default mode network
The default mode network includes hubs in the prefrontal cortex and posterior cingulate, with other prominent regions of the network in the medial temporal lobe and angular gyrus. The default mode network is usually active during mind-wandering and thinking about social situations. In contrast, during specific tasks probed in cognitive science (for example, simple attention tasks), the default network is often deactivated. Research has shown that regions in the default mode network (including medial prefrontal cortex and posterior cingulate) show greater activity when depressed participants ruminate (that is, when they engage in repetitive self-focused thinking) than when typical, healthy participants ruminate. People with MDD also show increased connectivity between the default mode network and the subgenual cingulate and the adjoining ventromedial prefrontal cortex in comparison to healthy individuals, individuals with dementia or with autism. Numerous studies suggest that the subgenual cingulate plays an important role in the dysfunction that characterizes major depression. The increased activation in the default mode network during rumination and the atypical connectivity between core default mode regions and the subgenual cingulate may underlie the tendency for depressed individual to get "stuck" in the negative, self-focused thoughts that often characterize depression. However, further research is needed to gain a precise understanding of how these network interactions map to specific symptoms of depression.
Salience network
The salience network is a cingulate-frontal operculum network that includes core nodes in the anterior cingulate and anterior insula. A salience network is a large-scale brain network involved in detecting and orienting the most pertinent of the external stimuli and internal events being presented. Individuals who have a tendency to experience negative emotional states (scoring high on measures of neuroticism) show an increase in the right anterior insula during decision-making, even if the decision has already been made. This atypically high activity in the right anterior insula is thought to contribute to the experience of negative and worrisome feelings. In major depressive disorder, anxiety is often a part of the emotional state that characterizes depression.
See also
Epigenetics of depression
The Mind Fixers
Anne Harrington § Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness
References
Further reading
Major depressive disorder
Mood disorders
Anatomy
Causes of mental disorders
Biological psychiatry
Behavioral neuroscience
sv:Depression#Biologiska hypoteser
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ASD
|
ASD most often refers to:
Autism spectrum disorder, a neurodevelopmental condition
Acute stress disorder, a psychological response
ASD may also refer to:
In science and technology
Biology
ASD (database), an online directory of allosteric proteins and their structure
Asd RNA motif, a structure in lactic-acid bacterium ribonucleic acid
Aspartate-semialdehyde dehydrogenase, an amino-acid-synthesising enzyme in plants, fungi and bacteria
Medicine
Antiseizure drug, an epilepsy medication
Antiseptic Dorogov's Stimulator, a Russian topical veterinary drug
Arthroscopic subacromial decompression, a surgical procedure on the shoulder
Atrial septal defect, a congenital heart defect
Computing
Accredited Symbian Developer, a computer programming qualification
Adaptive software development, a software development process
Aircraft and Scenery Designer, an add-on for the Microsoft Flight Simulator 4.0 video game
Application Specific Device, a Wi-Fi certification type
Other uses in science and technology
Active sound design, a technology used in cars to alter or enhance the sound inside and outside of the vehicle
Adjustable-speed drive, of an electric motor
Allowable stress design, a structural design methodology
Aspirating smoke detector, an indoor fire-protection device
Acceleration spectral density, a mechanical vibration test parameter
Transport
Aeronautical Systems Division (1961-1992), US Air Force technical division
Air Sinai, by ICAO code
Amsterdam Centraal railway station, station code
Andros Town International Airport, by IATA code
Slidell Airport, by FAA LID
Education
United States
Academy for Science and Design, Nashua, New Hampshire
Alabama School for the Deaf, part of the Alabama Institute for Deaf and Blind
Allentown School District, Pennsylvania
American School for the Deaf, West Hartford, Connecticut
Anchorage School District, Alaska
Armstrong School District (Pennsylvania)
Ashland School District (Oregon)
Avondale School District, Auburn Hills, Michigan
Other places
American School of Doha, Qatar
American School of Douala, Cameroon
American School of Dubai
Government and politics
AeroSpace and Defence Industries Association of Europe, a European business association
Alliance for Securing Democracy, a trans-Atlantic group
Alliance for Social Democracy, a political party in Benin
Architectural Services Department, Hong Kong
Australian Signals Directorate, intelligence agency
United States Assistant Secretary of Defense, one of several senior US Department of Defense officials
Other uses
ASD (album), 2015, by A Skylit Drive, an American band
Asas language, by its ISO 639 code
A. S. Byatt (born 1936), English critic, novelist, poet and short story writer, who was born Antonia Susan Drabble and whose married name is Antonia Susan Duffy
Association for the Study of Dreams
See also
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Hospitalism
|
Hospitalism (or anaclitic depression in its sublethal form) was a pediatric diagnosis used in the 1930s to describe infants who wasted away while in a hospital. The symptoms could include decreased physical development and disruption of perceptual-motor skills and language. In the first half of the 20th century, hospitalism was discovered to be linked to social deprivation between an infant and its caregiver. The term was in use in 1945, but the term can be traced back as early as 1897.
It appears under adjustment disorders at F43.2, in the World Health Organization's classification of diseases, ICD-10.
History
In 1945, the psychoanalyst René Spitz published an article in which he explained how deprivation of social interactions can lead to a condition named "hospitalism" in infants. According to Spitz, young children who are cared for in institutions can suffer from severe impairment in their development because they are not provided with sufficient maternal care. Spitz did not coin the term "hospitalism," which can be traced back to the end of the 19th century. In 1897 Floyd M. Crandall published an article in Archive of Pediatrics in which he used the term to describe a condition in institutionalized infants characterized by loss of weight, susceptibility to various diseases, and ultimately death. According to Crandall, this high mortality rate of institutionalized children under one-year-old was suspected to be caused by a lack of hygiene, food, air, exercise and personal contact.
After rapid growth in welfare centres for infants at the beginning of the 20th century, hospitalism became a more public concern. One solution that was offered was the improvement of general hygiene to avoid the spread of infections. Breastfeeding became increasingly important since it was considered to provide sufficient nutrition and to improve the infants' immune systems, which helped to reduce the mortality rate. The assumption that infants had no social competence or dependence on personal interactions had developed. Nurses began to replace the mothers' role for institutionalized infants, and mothers were usually not allowed to visit their children more than once a week. This was supposed to minimize the risk of infections and was considered to be a solution to hospitalism. The pediatrician Meinhard von Pfaundler criticized this approach and argued that this rational and distant care would damage the infants' physical and emotional well-being. He claimed that children needed more external stimulation than was provided in the environment of hospitals.
In the early 1930s researchers at the Vienna Psychological Institute started to concentrate on the development of infants. The so-called Viennese Baby Tests were created by Charlotte Bühler and could be used to assess the mental, social, and physical development of children. Katherine Wolf and Hildegard Durfee used these tests to conduct studies on infants in different institutions. They concluded that the environment influenced the development of children and that this was especially important for the development of social competence. According to them, infants needed to be in contact with their mothers to receive sufficient love and care for their development. In the 1940s, the idea that infections led to hospitalism was increasingly criticized, especially since hospitalized infants were often kept alone in small cubicles, without any contact with caregivers or external stimuli, to prevent cross-infections.
In 1945 the psychoanalyst René Spitz redefined the term hospitalism by arguing that the mortality rate of infants was still high, despite the isolation in cubicles, because the lack of maternal care impaired their development. Spitz conducted research for his hypothesis by comparing infants in a foundling hospital in Mexico and in a prison nursery in New York City with two control groups of children growing up with their families. With the help of Katherine Wolf, he assessed the development of the infants using the Viennese Baby Tests. Spitz concluded that the decline in development and the high susceptibility to diseases he discovered in institutionalized babies were not due to a lack of environmental stimuli, since the prison nursery infants actually had access to toys, but mostly due to emotional and social deprivation. According to Spitz, a stable and intimate mother-child relationship is critical for the healthy development of the child. In his short film Grief: A Peril in Infancy, he demonstrated the consequences of hospitalism. This idea had a strong influence on other researchers, and in 1951, the British psychoanalyst John Bowlby published a report on homeless children in the US. This report, which was titled Maternal Care and Mental Health, was commissioned by the WHO and supported his theory of maternal deprivation. According to Bowlby, a child needs to have a loving and continuous relationship with the mother to avoid permanent developmental damage and hospitalism.
Causes
Three conditions determine the likelihood of hospitalism in a patient:
How healthy the person is before the admission into the hospital
The efficacy of the operation or appointment
How the patient is taken care of after the operation or appointment, including the number of patients in the hospital in general and the hygiene of the hospital
The most investigated causes which have been observed are those from infants and children in hospitals or nursery homes. The main cause of hospitalism in children and infants is the separation of the child from the mother. They experience a massive desperation and distress due to the isolation from their mother. An example is children or infants in a nursery home when they are only held in cribs, depriving them of the opportunity to interact with their environment and other people. This deprivation might happen since the nurse has to take care of multiple children at once. A lot of causes, as well as assumptions of causes, still have to get scientifically proved and investigated.
Symptoms
Symptoms of hospitalism are numerous. Symptoms are largely observable in behaviour, but a patient's psychological or physical impairments are largely driven by the cause of their condition, and as such not all patients experience the same suite of problems. Physical impairments include physical underdevelopment, reduced motor speed, and increased risk of rapid-onset muscle atrophy. Patients commonly suffer from maladaptive or disruptive eating behaviour, which results in a general decrease in stamina. This has been linked to malnutrition, extreme weight loss, and food addiction. Patients tend to have a strong predisposition to marasmus, which increases mental and physical fragility, alongside an impairment of their immune system, leading them to be at higher risk for infections and viral diseases. Infants also experience a higher mortality rate. The psychological circumstances fit this image. Especially in children that stayed in orphanages for a long time and suffer from deprivation syndrome – the sensory withdrawal before adulthood resulting in physical and psychological damages – one can observe a reduction of activities due to a lack of motivation and suppression of feelings. Sleeplessness, loss of weight and apathy are additional symptoms of depression that can also play a role. Another effect of withdrawal of sensory desires in an early age are personality disorders as for example borderline and attachment and adjustment disorders that are especially seen in behavioral abnormalities.
These abnormalities can consist of stereotypes – a motor restlessness that results in showing repetitive and consistent motor processes and spoken utterances that do not have any goal or function and occur in absolutely unfitting situations. Stereotypic movement might also result in self harm. Behavioral abnormalities can also hinder social relations effectively. Affected individuals tend to become apathetic and withdrawn. Antisocial behavior might manifest as lying or stealing. Disrupted social functions related to a lack of socialization and integration can lead to further isolation. Hygiene and appearance may also be negatively impacted.
Consequences and complication
The consequences of hospitalism can be detrimental for the people affected and reveal themselves in different ways. It is noteworthy that the symptoms can vary across different individuals, and several factors, such as age, play a significant role.
Patients are also at higher risk for various mental disorders and anti-social behaviors:
anxiety disorders
depression
borderline-personality disorder
suicidal tendencies
apathy
low self-esteem
autoaggressive behaviour
attachment anxiety
adjustment and communication disorders
tendencies towards aggressive behaviour
lack of personal hygiene
Individuals suffering from hospitalism are also at risk for sensory perception problems:
altered or delayed pain perception
fear of touch
hypersensitivity
Other common consequences relate to cognitive disorders, such as:
learning disabilities
rarely memory lapses or even loss of long- or short-term memory
motor disorders such as monotonous and stereotyped movements (for example, banging the head against the wall) or a severely reduced ability to react
Long-term consequences, which is causally related to traumatic experiences, can be expressed in different ways. People showing signs of hospitalism might express an extreme aversion towards showing or accepting emotional or physical affection, effectively shutting themselves off from others. A different response could be promiscuity, whereas people strive for love and affection.
Prevention and solutions
Prevention and solutions of hospitalism largely focuses on efforts that seek to counter-act deprivation. During their stay, skin-to-skin contact between mother and child has shown to be beneficial. Also, conducting various types of play activities with children, which will meet their need for physical activity, can provide an opportunity to establish an intimate emotional relationship with the mother or a substitute. Therapeutic interventions should be carried out by specially trained professionals, psychotherapists, psychologists, social workers, teachers, and a network of non-professionals for people who are physically, mentally, or emotionally handicapped. Efforts are made to place parentless children in suitable accommodations, such as children's villages and foster care. Special attention should focus on the suitability of the environment for the child. These institutions should provide the necessary support and the right environment so that children can develop normally.
For the care of elderly and sick people assisted living and community houses are used for prevention. Accessibility and affordability are to continuously be improved. High-quality accommodation is also important for the proper treatment of existing illnesses and disorders. A very unique approach is lived in the Belgium city Geel, where it is common for people with mental illnesses to live with local families.
See also
Failure to thrive
Attachment theory
Maternal deprivation
Stress-related disorders
Philosophy of dialogue
Orphan
Feral child
Infant cognitive development
References
Encyclopedia of Childhood and Adolescence
Obsolete terms for mental disorders
Mood disorders
Child and adolescent psychiatry
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Mental healthcare in Nigeria
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Mental healthcare generally refers to services ranging from assessment, diagnosis, treatment, to counseling, dedicated to maintaining and restoring mental well being of people. In Nigeria, there is significant disparity between the demand and supply of mental health services. Though there are policies aimed at addressing mental health issues in Nigeria, in-depth information on mental health service in Nigeria is non-existent. This makes it difficult to identify areas of needs, coordinate activities of advocacy groups, and make an informed decision about policy direction. In effect, there is continued neglect of mental health issues. About 25-30 percent of Nigerians suffer from mental illness and less than 10 percent of this population have access to professional assistance. The World Health Organization estimates that only about three percent of the government's budget on health goes to mental health.
Mental health policies history
The Nigeria's mental health legislation was tagged lunacy ordinance and was first passed in 1916. It was amended in 1958 to grants medical practitioners and magistrates the authority to detain anyone suffering from mental illness, it was renamed the lunacy Act of 1958. Nigeria's mental health policy was first formulated in 1991. Its components include advocacy, promotion, prevention, treatment and rehabilitation.
In 2003, a bill for the establishment of Mental Health Act was introduced by Sen. Ibiabuye Martyns-Yellowe and Sen. Dalhatu Tafida but was later withdrawn in April 2009 after no considerable progress.
Four years later, precisely on March 20, 2013, the bill was re-introduced to the National Assembly by Hon. Samuel Babatunde Adejare and Hon. Solomon Olamilekan Adeola. The bill was proposed to protect the rights of persons with mental disorders, ensure equal access to treatment and care, discourage stigma and discrimination and set standards for psychiatric practice in Nigeria. The bill makes provisions for access to mental healthcare and services, Voluntary and involuntary treatment, accreditation of professional and facilities, Law enforcement and other judicial issues for people with mental illness, mechanisms to oversee involuntary admission and mechanism to implement the provision of Mental health Legislations. The bill was also not enacted.
Another mental health bill tagged Mental and Substance Abuse Bill was sponsored in 2019 by Senator Ibrahim Oloriegbe, representing Kwara Central Senatorial District in the 9th National Assembly, the bill was proposed to address the establishment and regulation of mental health and substance abuse services and to protect the right of people with mental health issues as well as to establish a commission for mental health. A public hearing for the bill took place on Feb 19, 2020 and was only signed into law in January 2023 by President Muhammad Buhari. [29]
Mental hospitals in Nigeria
The first mental hospitals in Nigeria are the Calabar Lunatic Asylum in southeastern Nigeria, and Yaba Lunatic Asylum in southwestern Nigeria. The latter, renamed Yaba Mental Hospital in 1961, and again given its current name Yaba Psychiatric Center (Federal Neuro Psychiatric Hospital) in 1977, admitted its first batch of 14 patients (8 women and 6 men) on 31 October 1907. The Yaba Lunatic Asylum which was situated in the former headquarters of the Nigeria Railways. In 1915, it became overcrowded, and some cells in Lagos prison were turned into Lunatic Asylum. Dr. Crispin Curtis Adeniyi Jones, a Nigerian Physician and also an official of the Lagos Medical Service became the first Director of the Lagos Lunatic Asylum.
Neuropsychiatric Hospital Aro, Abeokuta started as an asylum on the 13th of April, 1944 with 13 health attendants from the then Yaba Asylum ad five mentally ill patients. In 1948, the present site of Aro Neuropsychiatric Hospital of 732 acres was acquired for the hospital to carter for the overpopulation being experienced at the Lantoro annex. The renowned late Professor Thomas Adeoye Lambo (OFR) headed the main hospital at new site and brought the institute into spotlight through the creative 'Aro Village System' of treating the mentally ill. The institute became a WHO Collaborating Centre for Research and Training in Mental Health in August 1979. The institute has won different awards over the years - 2015 Best Primary Health Care Provider in Nigerian, 2010 Health Facility Utilization Award in Ogun state, 2007 best Specialty Hospital in Nigeria, 1999 most outstanding public sector organization in Nigerian.
Federal Neuro Psychiatric Hospital, Uselu, Benin City was first created in 1963, as an asylum with pioneer staff from Neuropsychiatric Hospital, Aro, Abeokuta. It is one of Nigeria federal government funded centers for Psychiatry in Nigeria.
The remaining federal government funded centers for Psychiatry are:
Federal Neuro-Psychiatric Hospital, Calabar
Federal Neuro-Psychiatric Hospital, Maiduguri
Federal Neuro-Psychiatric Hospital, Enugu
Federal Neuro-Psychiatric Hospital, Kaduna
Federal Neuro-Psychiatric Hospital, Kware
In addition to the Federal Neuro-Psychiatric Hospital, some Nigeria universities' teaching hospitals also have psychiatric units-
University of Benin Teaching Hospital, Edo
University College Hospital, Ibadan, Oyo
OAU Teaching Hospital Complex, Ile-Ife, Osun
University of Port Harcourt Teaching Hospital, Rivers
University of Calabar Teaching Hospital
University of Ilorin Teaching Hospital, Kwara
University Teaching Hospital, Jos, Plateau
Ahmadu Bello University Teaching Hospital, Kaduna
Usman Dan Fodio University Teaching Hospital, Sokoto
Aminu Kano University Teaching Hospital, Kano
University of Nsukka Teaching Hospital, Enugu
Mental health crisis in Nigeria
Shortage of psychiatrists and mental health support workers
One out of four Nigerians, an estimate of about 50 million people are living with some sort of mental illness. According to Nigerian Medical Association, 350 psychiatrists currently serve Nigerians with an estimated population of about 200 million people, this was stated during the celebration of 2020 World Mental Health Day. This is similar to the estimated number of 250 psychiatrists serving Nigerians claimed by Dr. Taiwo Sheikh, the president of the Association of Psychiatrists of Nigeria. Shortage of mental health professionals in addition to inadequate infrastructures and poor public attitudes towards mental illness has result to about 80 percent of people with serious mental illness unable to access adequate care.
Cultural and religious beliefs
Cultural and religious stereotypes has significant impact on the recovery process of people with mental health issues. Studies by Africa Polling Institute in collaboration with EpiAFRIC found that many Nigerians still associate mental illness with evil spirits, Voodoo and related supernatural causes. This misconception prompt many to seek treatment from religious leaders, traditional healers etc. Poor public education about mental health has allowed many misconception and low public acceptance of mental health patients to thrive.
According to Nigerian mental health expert, Aisha Bubah,"People do not have [an] understanding about mental health. So mental health gets attributed to so many cultural beliefs, superstitious beliefs and evil. And the image of mental health people have is always the extreme cases." In 2019, Human Rights Watch reported that thousands of people with mental illness are living in ankle chains at institutions designed for care. These, often religiously-run, centers are the only accessible option for many families.
Poor funding
Nigeria federal government has continuous earmarked less than 15% benchmark of health sector budget allocation agreed upon in April 2001 by leaders of the African Union (AU) at Abuja- 5.95% in 2012, 4.4% in 2014, 5.5% in 2015, 4.23% in 2016, 4.16% in 2017, 3.9% in 2018. Despite the low budget allocation for health care in Nigeria, mental health care does not have a clearly defined allocation from the total health care budget allocation. Funding of health care at State and local government level are even worse, with state and local government contributing 29% and 8% of total government spending in the care sector respectively in 2016.
References
Mental health in Nigeria
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Health human resources
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Health human resources (HHR) – also known as human resources for health (HRH) or health workforce – is defined as "all people engaged in actions whose primary intent is to enhance positive health outcomes", according to World Health Organization's World Health Report 2006. Human resources for health are identified as one of the six core building blocks of a health system. They include physicians, nursing professionals, pharmacists, midwives, dentists, allied health professions, community health workers, and other social service and health care providers.
Health human resources are further composed of health management and support personnel: those who do not provide direct patient care but add important value to enhance health system efficiency, effectiveness and equity. They include health services managers, medical records and health information technicians, health economists, health supply chain managers, medical secretaries, facility maintenance workers, and others.
The field of HHR deals with issues such as workforce planning and policy evaluation, recruitment and retention, training and development of skilled personnel, performance management, health workforce information systems, and research on health workforce strengthening. Raising awareness of the critical role of human resources in the health care sector - particularly as exacerbated by health labour shortages stemming from the Covid-19 pandemic - has placed the health workforce as one of the highest priorities of the global health agenda.
Global situation
The World Health Organization (WHO) raised the profile of HHR as a global health concern with its landmark 2006 published estimate of a shortage of almost 4.3 million physicians, midwives, nurses and support workers to meet the Millennium Development Goals, especially in sub-Saharan Africa. The situation was declared on World Health Day 2006 as a "health workforce crisis" – the result of decades of underinvestment in health worker education, training, wages, working environment and management. The WHO currently projects a global shortfall of 10 million health workers by 2030, mostly in low- and lower-middle income countries.
Shortages of skilled for health workers are also reported in many specific care areas. For example, there is an estimated shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries. Shortages of skilled birth attendants in many developing countries remains an important barrier to improving maternal health outcomes. Physiotherapists and rehabilitation medical specialists have been found to be less available in low- and middle-income countries, despite greater need.
Many countries, both developed and developing, report geographical maldistribution of skilled health workers leading to shortages in rural and underserved areas.
The advancement of global health security and universal health coverage (UHC) is hampered by a number of serious issues facing the global health workforce. The anticipated scarcity of health workers is a significant problem. The World Health Organisation (WHO) projects that by 2030, there will be a shortage of 18 million health workers worldwide, with low- and lower-middle-income nations bearing a disproportionate share of this burden. The provision of necessary health services is directly impacted by this scarcity, which also hinders the goal of establishing UHC. Access to healthcare is severely limited in many locations due to a shortage of skilled health personnel, particularly for disadvantaged populations.
The unequal distribution of health professionals, which clearly shows an urban-rural gap, is another issue. Health professionals are frequently more concentrated in urban areas, underserving isolated and rural locations. Rural communities suffer from worse health outcomes and unequal access to healthcare as a result of this discrepancy. Closing these disparities requires initiatives aimed at drawing and keeping health professionals in rural regions.
Imbalances in skills make matters more difficult. The requirements of the populace and the health workforce are sometimes at odds in many areas. For instance, there can be an excess of specialists and a deficiency of primary care physicians. This mismatch results in gaps in service delivery and ineffective use of human resources.
These difficulties have been made worse by the COVID-19 outbreak. Burnout, mental health problems, and higher attrition rates have been experienced by health professionals. According to a WHO poll conducted in 2022, stress associated to pandemics caused up to 40% of health personnel to consider quitting their employment. Maintaining healthcare systems requires addressing mental health assistance for healthcare professionals.
The health workforce is profoundly shaped by gender dynamics. Women make up over 70% of the workforce in the health sector worldwide, yet as of 2023, only 25% of leaders in health organisations were female. Healthcare policy formulation and decision-making are impacted by this gender disparity.
There is still a gender pay difference, even in wealthy nations. According to a 2022 study, female doctors make, on average, 24% less than their male colleagues.
There is also clear occupational segregation, with women occupying 90% of nursing positions worldwide while men still predominate in surgery (19% of women). Career options are restricted by this segmentation, which has its roots in societal conventions. Finally, intersectionality matters because women from minority backgrounds have more obstacles to career progression because of prejudice based on both race and gender.
Conclusion:
The COVID-19 pandemic's persistent effects, shortages, uneven distribution, and skill imbalances are placing a tremendous burden on the world's health workforce. Gender inequality not only presents structural obstacles but also persistently influences the lives and prospects of health workers across the globe. Coordinated international efforts are needed to solve these problems, with an emphasis on advancing gender equality, resolving skill gaps, and making sure that health professionals everywhere have the resources they need to deliver high-quality treatment. The international health community can endeavour to develop a more resilient and equitable health workforce by tackling these issues.
Regular statistical updates on the global health workforce situation are collated by the WHO's Global Health Observatory. However, the evidence base remains fragmented and incomplete, largely related to weaknesses in the underlying human resource information systems (HRIS) within countries.
In order to learn from best practices in addressing health workforce challenges and strengthening the evidence base, an increasing number of HHR practitioners from around the world are focusing on issues such as HHR advocacy, equity, surveillance and collaborative practice. Some examples of global HRH partnerships include:
Global Health Workforce Network
Women in Global Health
Health Workforce Information Reference Group (HIRG)
Research
Health workforce research is the investigation of how social, economic, organizational, political and policy factors affect access to health care professionals, and how the organization and composition of the workforce itself can affect health care delivery, quality, equity, and costs.
Many government health departments, academic institutions and related agencies have established research programs to identify and quantify the scope and nature of HHR problems leading to health policy in building an innovative and sustainable health services workforce in their jurisdiction. Some examples of HRH information and research dissemination programs include:
Human Resources for Health journal
HRH Knowledge Hub, University of New South Wales, Australia
Center for Health Workforce Studies, University of Albany, New York
Canadian Institute for Health Information: Spending and Health Workforce
Public Health Foundation of India: Human Resources for Health in India
National Human Resources for Health Observatory of Sudan
OECD Human Resources for Health Care Study
Training and Development
Training and development are vital, especially in the healthcare sector, as they ensure that the health force remains informed and educated about new advancements and innovations, which enhance patient safety and care. Similarly, by demonstrating to staff members that their professional development is valued, continuous professional development (CPD) increases job satisfaction and retention and lowers turnover rates. In addition, proficient personnel exhibit greater efficiency and adaptability, augmenting operational efficiency and facilitating healthcare establishments in fulfilling regulatory requirements. Furthermore, a dedication to continuous learning cultivates a climate of creativity and cooperation, which improves healthcare results.
Technological innovations have played a crucial role in the healthcare sector's ongoing growth. Consequently, healthcare companies must maintain their dedication to improving the competencies and expertise of their personnel, particularly in domains that offer a competitive edge. Knowledge management, training, and development are the three main components of organizational growth and development. Training and development, in Maimuna's opinion, are tools that help human capital explore their dexterity; as a result, they are essential to an organization's workforce's productivity. Digital education, if properly designed and implemented, can strengthen health workforce capacity by delivering education to remote areas and enabling continuous learning for health workers. World Health Organization (WHO) is developing guidelines on digital education for health workforce education and training. The WHO addresses the global health workforce crisis by providing comprehensive guidelines to improve health professional education and training that advocate for substantial educational reforms, including updating curricula, improving tutoring facilities, and revising admission criteria. It emphasizes the importance of increasing both the quantity and quality of healthcare professionals, making certain that they are adequately prepared to address evolving health needs, and highlights the necessity for interaction among the workforce, finance, health, and academic sectors to effectively implement these changes and achieve the overarching goal of developing a more efficient and suitable health workforce.
Types
Several Training Programs available in the health sector include:
1. Training in Leadership and Management Programs.
2. Training in Emergency Preparedness.
3. Continuing Professional Education.
4. Technical skill training.
5. Instruction in Patient Safety.
6. Cultural Competency Training.
Leadership Development
Leadership management and training is to ensure that the health force is established with skills and power to tackle the challenges and barriers experienced in the health sector. Training programs can often provide evidence-based teaching practices with experiential learning and are essential to developing successful and powerful leaders who can oversee the complexity of the healthcare system and can optimize patient outcomes. For instance, according to BMJ Leader, effective medical leadership programs frequently combine various teaching strategies, such as seminars, group projects, and action learning, which enhances results on several fronts. According to Medical Science Educators, transformational leadership is centered on developing trusting connections between leaders and subordinates, which improves job fulfillment, motivation, and staff loss, all leading to better healthcare delivery. Another study by Public Personnel Management examines how high-performance work systems and the job demands-resource theory relate to the impact of training and development access on employee engagement at work. The study demonstrates that greater rates of work engagement among federal employees are positively correlated with access to chances for training and development. It emphasizes how important it is for leaders to participate in leadership development programs because they give them the tools to create a positive work atmosphere that improves employee engagement and organizational performance.
Challenges and Solutions
Healthcare training and development encounter particular problems such as worker stress, scheduling conflicts, fast technology change, disease control protocols, and limited resources. Solutions for this include putting in place wellness initiatives, providing flexible and online training, ongoing education, and utilizing virtual reality (VR) technology to create comfortable training settings. Financial difficulties can also be lessened by obtaining grants and collaborations, and healthcare personnel can stay knowledgeable and proficient through simulation-based training, interprofessional collaboration, and ongoing professional development. Frequent evaluation and feedback increase the efficacy of training, which eventually improves staff satisfaction and patient care.
Future Trends
The adoption of technology, personal learning, and continuous professional development (CPD) are expected to be key components of future developments in healthcare training and development. Virtual reality (VR) and artificial intelligence (AI) are being used more frequently to provide stimulating and interactive training encounters. Considerable importance is placed on continuing education and professional development (CPD) to guarantee that healthcare personnel stay ahead with the most recent developments in medicine. The goal of these trends is to improve the treatment of patients and their results by strengthening the abilities and capabilities of healthcare professionals.
Policy and planning
In some countries and jurisdictions, health workforce planning is distributed among labour market participants. In others, there is an explicit policy or strategy adopted by governments and systems to plan for adequate numbers, distribution and quality of health workers to meet health care goals. For one, the International Council of Nurses reports:
The objective of HHRP [health human resources planning] is to provide the right number of health care workers with the right knowledge, skills, attitudes, and qualifications, performing the right tasks in the right place at the right time to achieve the right predetermined health targets.
An essential component of planned HRH targets is supply and demand modeling, or the use of appropriate data to link population health needs and/or health care delivery targets with human resources supply, distribution and productivity. The results are intended to be used to generate evidence-based policies to guide workforce sustainability. In resource-limited countries, HRH planning approaches are often driven by the needs of targeted programmes or projects, for example, those responding to the Millennium Development Goals or, more recently, the Sustainable Development Goals.
The WHO Workload Indicators of Staffing Need (WISN) is an HRH planning and management tool that can be adapted to local circumstances. It provides health managers a systematic way to make staffing decisions in order to better manage their human resources, based on a health worker's workload, with activity (time) standards applied for each workload component at a given health facility. Health workforce planning is essential for ensuring that health systems possess the appropriate number of skilled workers in suitable locations at optimal times to address care demands.The International Council of Nurses states that Health Human Resources Planning (HHRP) aims to synchronize the number of healthcare professionals with the requisite skills, attitudes, and qualifications to achieve established health objectives. Effective Health Human Resource Planning (HHRP) is heavily reliant on supply and demand modelling, utilizing data to connect population health requirements with the availability and productivity of human resources, hence facilitating workforce sustainability. Planning frequently emphasizes programmatic requirements, such as the Sustainable Development Goals (SDGs), in resource-constrained environments. The WHO workload Indicators of Staffing Need (WISN) tool aids in human resources for health planning by assisting health managers in making staffing decisions grounded in health workers' workloads and time standards at healthcare facilities.
Human Resource Planning (HRP) is essential to organizational success. It guarantees that appropriate people occupy suitable positions, promoting the effective execution of managerial tasks such as planning, organizing, and directing. In addition to employment, human resource planning encompasses tactics to enhance employee productivity and retention, including training, performance evaluations, and incentives. These employee engagement and reward methods are not just strategies, but a way to show appreciation and motivate the workforce. Effective human resource planning inspires people, increases productivity, and assures the seamless operation of organizations. Integrating data-driven workforce planning with these employee engagement and reward methods enables health systems and organizations to attain sustainable, long- term success.
Global Code of Practice on the International Recruitment of Health Personnel
The main international policy framework for addressing shortages and maldistribution of health professionals is the Global Code of Practice on the International Recruitment of Health Personnel, adopted by the WHO's 63rd World Health Assembly in 2010. The Code was developed in a context of increasing debate on international health worker recruitment, especially in some higher income countries, and its impact on the ability of many third-world countries to deliver primary health care services. Although non-binding on the Member States and recruitment agencies, the Code promotes principles and practices for the ethical international recruitment of health personnel. It also advocates the strengthening of health personnel information systems to support effective health workforce policies and planning in countries
Gender and health workforce
The WHO estimates women comprise approximately 70% of the global health workforce, but gender equality remains elusive. Women’s contributions to health and social care services are markedly undervalued; health labour markets around the world continue to be characterized with gender-based occupational segregation, inadequate work conditions free from gender bias and sexual harassment, gender pay gaps, and lack of gender parity in leadership. Numerous HHR studies have shown women healthcare providers earn significantly less on average than men despite similar professional titles, qualifications and job responsibilities. Meanwhile, an estimated 75% of HHR leadership roles are held by men.
See also
Health care providers
Health systems
Human resources for health information systems
Human Resources for Health, open access journal
Interprofessional education and collaborative practice in health care
Physician shortage / Nursing shortage
References
External links
World Health Organization programme of work on health human resources
Human Resources for Health Databases, Canadian Institute for Health Information
Human resources for health in developing countries – a dossier from the Institute for Development Studies
Compendium of tools and guidelines for HRH situation analysis, planning, policies and management systems
Online community of practice for HRH practitioners on strengthening health workforce information systems
Human Resources for Health Global Resource Center online collection of HRH research and materials, supported by the IntraHealth International-led CapacityPlus project
HRIS strengthening implementation toolkit
Africa Health Workforce Observatory
Human resource management
Health care occupations
Global health
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AH v West London Mental Health Trust
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AH vs West London Mental Health Trust was a landmark case in England, which established a legal precedent in 2011 when Albert Laszlo Haines (AH), a patient in Broadmoor Hospital, a high security psychiatric hospital, was able to exercise a right to a fully open public mental health review tribunal to hear his appeal for release. The case and the legal principles it affirmed have been described as opening up the secret world of tribunals and National Health Service secure units, and as having substantial ramifications for mental health professionals and solicitors, though how frequently patients will be willing or able to exercise the right is not yet clear.
The detention of Haines under the Mental Health Act had been continuous since 1986, mainly at Broadmoor Hospital run by West London Mental Health NHS Trust. The tribunal panel ultimately decided there were sufficient grounds for continued psychiatric detention but recommended better collaborative work towards psychiatric rehabilitation and gradual supported pathways to lower security then release to community mental health services.
Legal process
Gaining the right
Haines's request for his mental health tribunal to be fully open to the public was first made in 2009 but was turned down twice by the First-tier Tribunal. The justification for the refusal included claims that: Haines's primary intention was to air 'subjective grievances'; his evidence would not be 'objectively sensible'; he would be more difficult to control; the public would not be accurately informed; and the cost and the risk to the patient's health and conduct were disproportionate to any possible benefits.
In 2010 the Upper Tribunal ruled that the First Tier had erred in law, having not correctly identified or applied the principles it should have. In effect it had failed to uphold the fundamental principle that open justice is a right and it is the exceptions that must be justified, rather than vice versa. In addition to such a principle in common law, under Article 6 of the European Convention on Human Rights (Right to a fair trial), reinforced by the Convention on the Rights of Persons with Disabilities (Article 13 Access to justice), detained psychiatric patients have the same right as non-disabled detainees to have their case heard in public, provided they are mentally capable of giving informed consent for their right to patient confidentiality to be waived.
The Upper Tribunal therefore set aside the First Tier's decision, and was then at liberty to substitute its own decision. A short hearing was held for that purpose in February 2011, taking testimony from Broadmoor staff and Haines by video link. The panel concluded there was a sufficient rationale in Haines's case to grant an open appeal hearing, and that this was not offset by possible risks or extra costs. Broadmoor Hospital, run by West London Mental Health NHS Trust since 2001, had fought the decision.
Engaging in the hearing
The appeal hearing itself, the first ever to be open to the public and media, commenced in September 2011 in central London and lasted for two days. Mr Haines's consultant psychiatrist, Dr Jose Romero-Urcelay, was cross-examined for one day. Haines's ward clinical nurse manager, social worker and hospital 'independent' patient advocate also testified. Haines himself submitted a written report and testified for 20 minutes. Evidence was also heard from an independent social worker and from Albert Haines's brother Leigh, who was offering to house and support him should he be released.
The decision was that Haines should not yet be released, even conditionally to a lower security facility. The reasons for the decision were published two weeks later, for the first time ever and contrary to a written representation submitted on behalf of Haines. The three-member panel headed by Judge McGregor-Johnson, Honorary Recorder, concluded that under the Mental Health Act Mr Haines was still considered to have a mental disorder of a nature or degree to justify detention in hospital for treatment, and that he still presented a sufficient risk to others and himself. However, Broadmoor Hospital staff were urged to find a way to better engage with Haines, even if that meant starting treatment on his own terms, and to put a clear pathway in place so that Haines could see an acceptable way to progress to lower security facilities and eventual release.
Haines's solicitor, Kate Luscombe of the firm Duncan Lewis, said her client had received fair public support, had been able to air his grievances, and had followed the proceedings appropriately throughout; however she said Haines was disappointed at the final judgements and questioned whether his treatment over 25 years had promoted his rehabilitation. A spokesperson for West London NHS stated they were pleased the hearing was over due to the burden it being public put on the hospital's resources, that they thought the verdict agreed that Broadmoor was the best treatment environment presently, but that they would continue to seek ways to engage Haines in treatment. Albert Haines's sister Denise, however, stated that she believed Albert could not get the kind of help he needs at Broadmoor and fears he would not come out alive.
Personal background
The legal process made extensive reference to Haines's life as a child and adult, and he was the focus of some national press coverage which included personal interviews. Born in 1959 in Hammersmith, London, Albert Haines suffered neglect and abuse from a young age. He was put in residential care for many years, as were his three sisters and two brothers. A mental health assessment at just five years of age described him as 'emotionally maladjusted'. He was sexually and physically abused. After leaving residential homes once an adult, Haines stayed in hostels, bedsits or on the streets. He drank alcohol and took cannabis, cocaine and amphetamines. He was convicted of criminal damage in 1979 and in 1980 for possession of an offensive weapon. He was in and out of psychiatric hospitals.
In May 1986 while a patient of the Maudsley Hospital run by South London and Maudsley NHS Trust, Haines went in carrying a machete and a small knife. There is some disagreement between media reports as to whether he threatened staff and gave himself up, or tried to attack a member of staff but was prevented. No one was physically hurt. Later that year he pleaded guilty to attempted wounding. Rather than being sentenced to prison, he was sent to Broadmoor high-security psychiatric hospital for treatment under the Mental Health Act.
In 1992 Haines was transferred to the medium secure Three Bridges Unit in Ealing, London, also now run by West London Mental Health NHS Trust. While there he made successful visits out of hospital and worked in catering without incident, but after a confrontation with hospital staff involving being put in seclusion after brandishing a fire extinguisher and climbing onto the roof, he was returned to Broadmoor in 2008.
Psychiatric context
According to the tribunal, Albert Haines was long diagnosed with a personality disorder – meaning an enduring and pervasive difficulty that developed by at least adolescence/early adulthood and which especially affects social interaction. The panel noted that several psychiatric reports have concluded that Haines demonstrates features of either emotionally unstable personality disorder and/or antisocial personality disorder. They also referred to childhood conduct disorder being demonstrated by his historical records. References were also made to 'psychopathic disorder', a legal category in the Mental Health Act 1983 which could cover any persistent mental disorder if it appeared to lead (in the individual case) to abnormally aggressive or irresponsible conduct; the category was abolished by amendments in the Mental Health Act 2007 which came into force in 2008. A separate political-administrative category of "Dangerous and Severe Personality Disorder" had been introduced in the UK from the turn of the 21st century, and one of four DSPD units nationwide was at Broadmoor Hospital although it is not clear whether Haines was considered under this category.
According to the tribunal, Mr Haines was also long found to have a mental illness in addition to underlying personality disorder, but in 2008 was rediagnosed as having a personality disorder only. Dr Romero-Urcelay of Broadmoor testified that Haines does suffer from a psychotic illness with specific persecutory delusions, at least since he was returned to Broadmoor from Three Bridges in 2008 and refused to accept any treatment from them. Other psychiatrists have not concluded that he has a psychotic illness at all, while others have gone further in concluding that he has a generalised psychosis which meets the criteria for schizoaffective disorder.
At his hearing, Haines disputed the diagnoses of personality disorder and psychosis, although he accepted that he had difficulties. He refused to accept the type of treatment offered by Broadmoor even if any release or step-down in security was conditional on it. He said that as a vulnerable young man he had looked to the experts for help but had been given multiple diagnoses, forced medication and incarceration. He said that trauma from his childhood abuse had not been properly recognised or reported for 25 years and that non-directive counselling had never been offered despite his asking for it ever since he could remember.
See also
Forensic psychiatry
Campaign for John Hunt
References
External links
Decision of the Upper Tribunal to set aside the First Tier's refusal to hold its Tribunal hearing in public Bailii legal database, AH v West London Mental Health Trust [2010] UKUT 264 (AAC) (29 July 2010).
Decision of the Upper Tribunal to grant a public First Tier Tribunal hearing Bailii legal database, AH v West London Mental Health Trust & the SoS (J) [2011] UKUT 74 (AAC) (17 February 2011).
Verdict of the public First-tier Mental Health Tribunal hearing - Case Number: MP/2010/19311 - Restricted Patient: Albert Laszlo Haines, Judiciary of England, October 2011.
BBC video clips of Denise Haines, with artwork sent by her brother, and some of the professionals involved in the case 26 October 2011
Psychiatry controversies
Anti-psychiatry
Mental health legal history of the United Kingdom
United Kingdom disability case law
Mental health case law
2011 in United Kingdom case law
| 0.774621 | 0.967921 | 0.749772 |
Narrative inquiry
|
Narrative inquiry or narrative analysis emerged as a discipline from within the broader field of qualitative research in the early 20th century, as evidence exists that this method was used in psychology and sociology. Narrative inquiry uses field texts, such as stories, autobiography, journals, field notes, letters, conversations, interviews, family stories, photos (and other artifacts), and life experience, as the units of analysis to research and understand the way people create meaning in their lives as narratives.
Narrative inquiry has been employed as a tool for analysis in the fields of cognitive science, organizational studies, knowledge theory, applied linguistics, sociology, occupational science and education studies, among others. Other approaches include the development of quantitative methods and tools based on the large volume captured by fragmented anecdotal material, and that which is self signified or indexed at the point of capture. Narrative inquiry challenges the philosophy behind quantitative/grounded data-gathering and questions the idea of "objective" data; however, it has been criticized for not being "theoretical enough." In disciplines like applied linguistics, scholarly work has pointed out that enough critical mass of studies exists in the discipline that uses this theory, and that a framework can be developed to guide its application.
Background
Narrative inquiry is a form of qualitative research, that emerged in the field of management science and later also developed in the field of knowledge management, which shares the sphere of information management. Narrative case studies were used by Sigmund Freud in the field of psychology, and biographies were used in sociology in the early twentieth century. Thus narrative inquiry focuses on the organization of human knowledge more than merely the collection and processing of data. It also implies that knowledge itself is considered valuable and noteworthy even when known by only one person.
Knowledge management was coined as a discipline in the early 1980s as a method of identifying, representing, sharing, and communicating knowledge. Knowledge management and narrative inquiry share the idea of knowledge transfer, a theory which seeks to transfer unquantifiable elements of knowledge, including experience. Knowledge, if not communicated, becomes arguably useless, literally unused.
Philosopher Andy Clark speculates that the ways in which minds deal with narrative (second-hand information) and memory (first-hand perception) are cognitively indistinguishable. Narrative, then, becomes an effective and powerful method of transferring knowledge.
More recently, there has been a "narrative turn" in social science in response to the criticism against the paradigmatic methods of research. It has also been forecasted that soon narrative inquiry will emerge as an independent research method as opposed to being an extension of the qualitative method.
Narrative ways of knowing
Narrative is a powerful tool in the transfer, or sharing, of knowledge, one that is bound to cognitive issues of memory, constructed memory, and perceived memory. Jerome Bruner discusses this issue in his 1990 book, Acts of Meaning, where he considers the narrative form as a non-neutral rhetorical account that aims at "illocutionary intentions", or the desire to communicate meaning. This technique might be called "narrative" or defined as a particular branch of storytelling within the narrative method. Bruner's approach places the narrative in time, to "assume an experience of time" rather than just making reference to historical time.
This narrative approach captures the emotion of the moment described, rendering the event active rather than passive, infused with the latent meaning being communicated by the teller. Two concepts are thus tied to narrative storytelling: memory and notions of time; both as time as found in the past and time as re-lived in the present.
A narrative method accepts the idea that knowledge can be held in stories that can be relayed, stored, and retrieved. There is also a view that a critical event can play an important role as creating the context of a narrative to be captured.
Method
1. Develop a research question
A qualitative study seeks to learn why or how, so the writer's research must be directed at determining the why and how of the research topic. Therefore, when crafting a research question for a qualitative study, the writer will need to ask a why or how question about the topic.
2. Select or produce raw data
The raw data tend to be interview transcriptions, but can also be the result of field notes compiled during participant observation or from other forms of data collection that can be used to produce a narrative.
3. Organize data
According to psychology professor Donald Polkinghorne, the goal of organizing data is to refine the research question and separate irrelevant or redundant information from that which will be eventually analyzed, sometimes referred to as "narrative smoothing."
Some approaches to organizing data are as follows:
(When choosing a method of organization, one should choose the approach best suited to the research question and the goal of the project. For instance, Gee's method of organization would be best if studying the role language plays in narrative construction whereas Labov's method would more ideal for examining a certain event and its effect on an individual's experiences.)
Labov's: Thematic organization or Synchronic Organization.
This method is considered useful for understanding major events in the narrative and the effect those events have on the individual constructing the narrative. The approach utilizes an "evaluation model" that organizes the data into an abstract (What was this about?), an orientation (Who? What? When? Where?), a complication (Then what happened?), an evaluation (So what?), a result (What finally happened?), and a coda (the finished narrative). Said narrative elements may not occur in a constant order; multiple or reoccurring elements may exist within a single narrative.
Polkinghorne's: Chronological Organization or Diachronic Organization
also related to the sociology of stories approach that focuses on the contexts in which narratives are constructed. This approach attends to the "embodied nature" of the person telling the narrative, the context from which the narrative is created, the relationships between the narrative teller and others within the narrative, historical continuity, and the chronological organization of events. A story with a clear beginning, middle, and end is constructed from the narrative data. Polkinghorne makes the distinction between narrative analysis and analysis of narratives. Narrative analysis utilizes "narrative reasoning" by shaping data in a narrative form and doing an in-depth analysis of each narrative on its own, whereas analysis of narratives utilizes paradigmatic reasoning and analyzes themes across data that take the form of narratives.
Bruner's functional approach focuses on what roles narratives serve for different individuals. In this approach, narratives are viewed as the way in which individuals construct and make sense of reality as well as the ways in which meanings are created and shared. This is considered a functional approach to narrative analysis because the emphasis of the analysis is focused on the work that the narrative serves in helping individuals make sense of their lives, particularly through shaping random and chaotic events into a coherent narrative that makes the events easier to handle by giving them meaning. The focus of this form of analysis is on the interpretations of events related in the narratives by the individual telling the story.
Gee's approach of structural analysis focuses on the ways in which the narrative is conveyed by the speaker with particular emphasis given to the interaction between the speaker and the listener. In this form of analysis, the language that the speaker uses is the focus. This includes the language, the pauses in speech, discourse markers, and other similar structural aspects. In this approach, the narrative is divided into stanzas and each stanza is analyzed by itself and also in the way in which it connects to the other pieces of the narrative.
Jaber F. Gubrium's form of narrative ethnography features the storytelling process as much as the story in analyzing narrativity. Moving from text to field, he and his associate James A. Holstein present an analytic vocabulary and procedural strategies for collecting and analyzing narrative material in everyday contexts, such as families and care settings. In their view, the structure and meaning of texts cannot be understood separate from the everyday contexts of their production. Their two books--"Analyzing Narrative Reality" and "Varieties of Narrative Analysis" provide dimensions of an institutionally-sensitive, constructionist approach to narrative production.
There are a multitude of ways of organizing narrative data that fall under narrative analysis; different types of research questions lend themselves to different approaches. Regardless of the approach, qualitative researchers organize their data into groups based on various common traits.
4. Interpret data
Some paradigms/theories that can be used to interpret data:
{| class="wikitable"
|-
! Paradigm or theory !! Criteria !! Form of theory !! Type of narration
|-
| Positivist/postpositivist || Universalist, evidence-based, internal, external validity || Logical-deductive grounded || Scientific report
|-
| Constructivist || Trustworthiness, credibility, transferability, confirmability || Substantive || Interpretive case studies, ethnographic fiction
|-
| Feminist || Afrocentric, lived experience, dialogue, caring, accountability, race, class, gender, reflexivity, praxis, emotion, concrete grounding || Critical, standpoint || Essays, stories, experimental writing
|-
| Ethnic || Afrocentric, lived experience, dialogue, caring, accountability, race, class, gender || Standpoint, critical, historical || Essays, fables, dramas
|-
| Marxism || Emancipatory theory, falsifiability dialogical, race, class, gender || Critical, historical, economic || Historical, economic, sociocultural analyses
|-
| Cultural studies || Cultural practices, praxis, social texts, subjectivities || Social criticism || Cultural theory as criticism
|-
| Queer theory || Reflexivity, deconstruction || Social criticism, historical analysis || Theory as criticism, autobiography
|}
While interpreting qualitative data, researchers suggest looking for patterns, themes, and regularities as well as contrasts, paradoxes, and irregularities.
(The research question may have to change at this stage if the data does not offer insight to the inquiry.)
The interpretation is seen in some approaches as co-created by not only the interviewer but also with help from the interviewee, as the researcher uses the interpretation given by the interviewee while also constructing their own meaning from the narrative.
With these approaches, the researcher should draw upon their own knowledge and the research to label the narrative.
According to some qualitative researchers, the goal of data interpretation is to facilitate the interviewee's experience of the story through a narrative form.
Narrative forms are produced by constructing a coherent story from the data and looking at the data from the perspective of one's research question.
Interpretive research
The idea of imagination is where narrative inquiry and storytelling converge within narrative methodologies. Within narrative inquiry, storytelling seeks to better understand the "why" behind human action. Story collecting as a form of narrative inquiry allows the research participants to put the data into their own words and reveal the latent "why" behind their assertions.
"Interpretive research" is a form of field research methodology that also searches for the subjective "why". Interpretive research, using methods such as those termed ""storytelling" or "narrative inquiry", does not attempt to predefine independent variables and dependent variables, but acknowledges context and seeks to "understand phenomena through the meanings that people assign to them."
Two influential proponents of a narrative research model are Mark Johnson and Alasdair MacIntyre. In his work on experiential, embodied metaphors, Johnson encourages the researcher to challenge "how you see knowledge as embodied, embedded in a culture based on narrative unity," the "construct of continuity in individual lives."
The seven "functions of narrative work" as outlined by Catherine Kohler Riessman:
Narrative constitutes past experiences as it provides ways for individuals to make sense of the past.
Narrators argue with stories.
Persuading. Using rhetorical skill to position a statement to make it persuasive/to tell it how it "really" happened. To give it authenticity or 'truth'.
Engagement, keeping the audience in the dynamic relationship with the narrator.
Entertainment.
Stories can function to mislead an audience.
Stories can mobilize others into action for progressive change.
Practices
Narrative analysis therefore can be used to acquire a deeper understanding of the ways in which a few individuals organize and derive meaning from events. It can be particularly useful for studying the impact of social structures on an individual and how that relates to identity, intimate relationships, and family. For example:
Feminist scholars have found narrative analysis useful for data collection of perspectives that have been traditionally marginalized. The method is also appropriate to cross-cultural research. As Michael Brecher and Frank P. Harvey advocate, when asking unusual questions it is logical to ask them in an unusual manner.
Developmental psychology utilizes narrative inquiry to depict a child's experiences in areas such as self-regulation, problem-solving and development of self.
Personality uses the narrative approach in order to illustrate an individual's identity over a lifespan.
Social movements have used narrative analysis in their persuasive techniques.
Political practices. Stories are connected to the flow of power in the wider world. Some narratives serve different purposes for individuals and others, for groups. Some narratives overlap both individual experiences and social.
Promulgation of a culture: Narratives and storytelling are used to remember past events, reveal morals, entertain, relate to one another, and engage a community. Narrative inquiry helps to create an identity and demonstrate/carry on cultural values/traditions. Stories connect humans to each other and to their culture. These cultural definitions aid to make social knowledge accessible to people who are unfamiliar with the culture/situation. An example of this is how children in a given society learn from their parents and the culture around them.
Notable people
Jerome Bruner
D. Jean Clandinin
F. Michael Connelly
James Paul Gee
Jaber F. Gubrium
Mark Johnson
William Labov
Carl Leggo
Alasdair MacIntyre
Elliott Mishler
Catherine Kohler Riessman
Donald Polkinghorne
See also
Content analysis
Frame analysis
Hermeneutics
Narrative psychology
Narratology
Organizational storytelling
Praxis intervention
Thematic analysis
Reflective practice
References
Bibliography
David M. Boje, Narrative Methods for Organizational and Communication Research (Thousand Oaks, CA: Sage, 2001).
Barbara Czarniawska-Joerges, Narratives in Social Science Research (Thousand Oaks, CA: Sage, 2004).
D. Jean Clandinin and F. Michael Connelly, Narrative Inquiry: Experience and Story in Qualitative Research (San Francisco: Jossey-Bass Publishers, 2000).
F. Michael Connelly and D. Jean Clandinin, "Stories of Experience and Narrative Inquiry." Educational Researcher 19, no. 5 (June–July 1990): 2–14.
C. Conle, "Narrative Inquiry: Research Tool and Medium for Professional Development," European Journal of Teacher Education 23, no.1 (March 2000): 49–63.
Jaber F. Gubrium & James A. Holstein. 2009. "Analyzing Narrative Reality." Thousand Oaks, CA: Sage.
James A. Holstein & Jaber F. Gubrium (eds.). 2012. "Varieties of Narrative Analysis." Thousand Oaks, CA: Sage.
Nona Lyons and Vicki Kubler LaBoskey, Narrative Inquiry in Practice: Advancing the Knowledge of Teaching (New York: Teachers College Press, 2002).
Lene Nielsen and Sabine Madsen, "Storytelling as Method for Sharing Knowledge across IT Projects," Proceedings of the 39th Hawaii International Conference on System Sciences, 2006
Gary Oliver and Dave Snowden, "Patterns of Narrative in Organizational Knowledge Sharing," in Knowledge Management and Narratives: Organizational Effectiveness Through Storytelling, Georg Schreyögg and Joch Koch, eds. (Berlin: Erich Schmidt Verlag, 2005).
Gian Pagnucci, Living the Narrative Life: Stories as a Tool for Meaning Making (Portsmouth, NH: Boynton/Cook, 2004).
Donald Polkinghorne, Narrative Knowing and the Human Sciences (Albany: SUNY Press, 1988).
Dave Snowden, "Complex Acts of Knowing: Paradox and Descriptive Self-Awareness," Journal of Knowledge Management 6, no. 2 (Spring 2002): 100–111.
Dave Snowden, "Narrative Patterns: the perils and possibilities of using story in organisations," in Creating Value With Knowledge, Eric Lesser and Laurence Prusak, eds. (Oxford: Oxford University Press, 2004).
Organizational studies
Cognitive science
Qualitative research
Inquiry
Intellectual capital
| 0.762294 | 0.983509 | 0.749723 |
Locura
|
Locura, which translates to "insanity" in Spanish, is a mental disorder characterized as severe chronic psychosis. The term refers to a culture-bound syndrome, found mostly in Latin America and Latin Americans in the United States. Also referred to as ataques de locura (meaning "madness attacks"), it is categorized as a more severe form of nervios ataque de nervios with symptoms appearing similar to those of schizophrenia.
Hispanic families describing affected loved ones with "nervios" often focused on the "agitated behavior" and how it progresses into the belief that the affected loved one will fall more "susceptible to many health problems". Many families, most notably of Hispanic origin, believe that children are more vulnerable to developing such symptoms as their "nerves" (translation from spanish), are more prone to being damaged; a belief that is relatively prevalent amongst such communities.
As the term may have multiple meanings in multiple environments, research on locura is limited and conflicting. The term can be used loosely in Spanish when discussing madness in other psychological meaning, specifically describing a "deviance from the norm due to mental illness." Besides for the implications found in the DSM-IV, the word is not used in English.
Classification
In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), locura is classified as a culture-bound syndrome. Culture-bound syndromes can be found in an appendix of the manual named, Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes. However, the DSM - 5 does not include locura in its equivalent appendix named, Glossary of Cultural Concepts of Distress. One author chooses to describe the symptoms as correlating to a somatoform disorder of conversive type.
Signs and symptoms
Locura is thought to develop during times of stress or vulnerability in one's life, as well as the accumulation of difficulties or traumas. Another possible cause is through the manifestation of supernatural maneuvers, or maleficios (meaning "curses").
The DSM-IV includes symptoms of incoherence, agitation, inability to follow rules of social interaction, unpredictability, and possible violence. Other sources include headache, fainting, convulsive attacks, difficulty in breathing, an urge to run away, hallucinations, and visions of people, visions, or demons.
History
Locura has been examined in an indigenous group in Colombia called Embera. After four members of the Embera community began exhibiting symptoms later described as, "repetitive episodes of what resembled a dissociative fugue disorder," a local shaman explained that the outbreak could be attributed to a shaman from a different region. The local shaman attempted their own treatment, but the affected member's symptoms continued and after six months, they eventually chose to seek help in the closest province. Soon after they arrived, their local relatives began to develop the same symptoms. After five more individuals presented similarly, all nine members began seeking forms of treatment including care from different types of religious healers, psychiatrists, and antipsychotic drugs. After none of these tactics proved successful, a shaman from the Chocó province in Colombia was brought to attempt treatment. The shaman's treatments reportedly reduced the frequency of the symptoms greatly in all of the patients and eliminated symptoms completely in two patients.
See also
Ataques de nervios
Culture-bound syndrome
References
Psychopathological syndromes
Culture-bound syndromes
| 0.775045 | 0.967299 | 0.7497 |
Internet Brands
|
MH Sub I, LLC d/b/a Internet Brands is a digital media, marketing services, and software company based in El Segundo, California, United States, that operates online media, community, e-commerce, and SaaS businesses in vertical markets. is a digital media, marketing services, and software company based in El Segundo, California, United States, that operates online media, community, e-commerce, and SaaS businesses in vertical markets. Its largest businesses are in online health and legal services. The company's website indicates that it employs more than 7,000 people globally.
Businesses
WebMD and Medscape
The company acquired its largest businesses, WebMD and Medscape, in a $2.8 billion transaction in 2017. In 2018, WebMD acquired Frontline Communications and Jobson. In 2019, WebMD acquired Aptus Health from Merck. In 2020, WebMD acquired: StayWell and Krames, also from Merck; and Germany-based Coliquio. In 2021, WebMD acquired ADDitude and the Wellness Network. In 2022, WebMD acquired Mercury Health Care, a spinout of Healthgrades. Also in 2022, WebMD acquired Jim.fr, a medical news and information website for physicians based in France. In 2023, Internet Brands acquired Limeade, a digital health and wellness platform, as well as Grupo Saned, a health and medical information services company in Spain. In 2024, WebMD acquired the operating assets of Healthwise, a provider of patient health education materials.
Legal Division
The company's legal division serves consumers and attorneys and includes FindLaw, Avvo, Martindale Hubbell, and Nolo. Its services and platforms for attorneys were collectively rebranded Martindale-Avvo in 2018. The company's Martindale Hubbell ownership originated in 2013 as a Joint Venture with LexisNexis, though the Martindale business traces its roots to 1868.
Pulsepoint
The company acquired Pulsepoint, a programmatic online ad tech company, in 2021.
Dental Division
Internet Brands and Henry Schein formed a joint venture in 2018, called Henry Schein One (HS1), contributing the dental software and internet businesses of both companies. In 2019, HS1 acquired Lighthouse 360. In 2020, HS1 acquired United Kingdom-based Dentally. In 2021, HS1 acquired Jarvis Analytics.
Consumer Internet division
As of its 2009 public filings, the consumer internet division owned and operated more than 95 websites in seven categories and attracted more than 62 million unique visitors per month, with 97% of the audience originating from organic, non-paid sources. The company's strategy is to focus on specific target audiences that tend to be attractive to advertisers.
In 2016, the company acquired Fodor's travel, which was joined with other travel properties such as Wikitravel and FlyerTalk.
On December 1, 2010, Internet Brands acquired AllLaw.com and AttorneyLocate.com, both founded by Arvind A. Raichur.
In 2007, the company acquired Corvette Forum and in 2004, a Chevy Corvette enthusiast site.
SEC filings indicate that approximately 70% of the company's revenues are derived from advertising from more than 40,000 accounts—most of them small and medium enterprises.
The company's portfolio of websites include many with social media features: social network services, user generated content, blogs, wikis, and internet forums.
History
The company was founded in 1998 as CarsDirect.com, launched from the business incubator Idealab. The company invented a consumer-advocacy approach to selling cars "haggle-free" online, an approach it continues to employ. In 2000, Roger Penske invested in the company and joined the Board of Directors. That same year, the company was the title sponsor of the 2000 CarsDirect.com 400, an event in the NASCAR Winston Cup Series, to bring attention to online car buying. In 2002, Time Magazine voted the site one of the 50 best in the world.
The company changed its name to Internet Brands in 2005. The company's IPO was in November 2007 on the NASDAQ exchange. INET was added to the NASDAQ Internet Index on March 22, 2010.
Internet Brands agreed to be acquired for $640 million by the private equity firm Hellman & Friedman in September 2010 and was thus delisted from NASDAQ.
In September 2012, Internet Brands became involved in a legal battle with the Wikimedia Foundation (the operators of Wikipedia) over the future of Wikitravel's community.
Internet Brands was acquired in June 2014 by KKR from Hellman & Friedman for 1.1 billion dollars. KKR is making its investment in partnership with Internet Brands chief executive officer Bob Brisco and the Internet Brands management team, who will hold a minority stake in the company and continue to run the business.
In January 2016, Intuit Inc. announced an agreement to sell Demandforce to Internet Brands.
In October 2024, Thomson Reuters announced it would sell online legal information provider FindLaw to Internet Brands.
Charity and Community
Health Heroes
Each year WebMD presents Health Heroes awards, a recognition program of health care leaders, conducted by its editorial staff. Recently, the annual awards have focused on a specific topic, such as children's mental health in 2022, COVID-19 frontline workers in 2021, and Social justice in health care in 2020.
Annenberg Journalism Awards
In 2022, WebMD also began a partnership with the USC Annenberg School for Communication and Journalism's Center For Health Journalism, establishing a reporting fund in honor of the company's long-time editor Kristy Hammam.
Homelessness
The company has been involved in several aspects of homeless charity, including extensive reporting, direct charity, and an annual fund raiser held in Santa Monica.
Controversies
vBulletin criticism
In October 2009, Internet Brands changed the pricing structure for its vBulletin software, prompting complaints from registered users on the official forums. According to The Register those who complained were then banned from both the forums and from receiving support and updates, despite still having valid licences for the product. Internet Brands defended their position to The Register in a separate article; however, a later update to the same article stated that at least some of Internet Brands' claims were false. In October 2010, Internet Brands announced that it would file a lawsuit against the XenForo team claiming copyright infringement; specifically that code in XenForo was based on vBulletin code, breach of contract, and engaging in unfair business practices. In November 2010, Internet Brands sued Kier Darby, a lead developer of XenForo, who had previously served as a lead developer for Internet Brands' vBulletin, claiming that Kier had not returned confidential information from Internet Brands regarding the vBulletin software. The XenForo team has denied the claims. In February 2013, the lawsuit was dismissed.
Wikitravel and Wikimedia
In 2012, after a lengthy history of dissatisfaction, community members at Internet Brands-owned website Wikitravel began discussing whether to fork (split off) of their work and editing activities from Wikitravel and recommence their editing activities at another website host. The dissatisfaction related to long standing discontent at poor hosting, poor site updates, and excessive over-monetarization and advertising, and eventually, interference by Internet Brands in the community's activities in breach of prior agreements and understandings.
Forking is a normal or anticipated activity in wiki communities and is permitted by the Creative Commons license in use on sites such as Wikitravel, and the wiki software used by Wikitravel included the facility to take 'database "dumps"' for that purpose. This mirrored the fork of the German and Italian language Wikitravel communities some years earlier, which led to a new travel wiki site called Wikivoyage. Members of the communities concerned decided that the community at Wikitravel would move its editing efforts to merge with Wikivoyage, to create a new travel wiki to be hosted by the Wikimedia Foundation, the owner of Wikipedia and a large range of other non-profit reference sites based upon a wiki community.
The merge and move were endorsed by the editing community, but opposed by Internet Brands who litigated against two users it accused of unlawful actions related to the proposal. The allegations were strongly rejected by the individuals and the (non-party) Wikimedia Foundation who stated the case was an example of a SLAPP lawsuit intended to deter and frustrate lawful conduct. On November 19, 2012, the claims by Internet Brands were dismissed by the United States District Court for the Central District of California.
Greenlight Financial Services
In April 2013, on behalf of its client Greenlight Financial Services, Inc., the Rhema Law Group won a jury verdict trial against Internet Brands, Inc. The Orange County Superior Court jury found that Internet Brands breached a previous settlement agreement between the parties and awarded lost profits damages in the amount of $750,000.
Model Mayhem
ModelMayhem.com is a social media website where models can create profiles and publish pictures. In May 2008, Internet Brands bought Model Mayhem from the original developers Donald and Tyler Waitt. Model Mayhem was involved in the court case Jane Doe No. 14 v. Internet Brands, Inc., where litigants argued that Model Mayhem was liable for damages resulting from crimes committed by users on the website.
References
External links
Mass media companies established in 1998
American companies established in 1998
Online mass media companies of the United States
Technology companies based in Greater Los Angeles
Companies based in El Segundo, California
Kohlberg Kravis Roberts companies
1998 establishments in California
2007 initial public offerings
Companies formerly listed on the Nasdaq
2010 mergers and acquisitions
2014 mergers and acquisitions
| 0.76273 | 0.982909 | 0.749694 |
Neurocognition
|
Neurocognitive functions are cognitive functions closely linked to the function of particular areas, neural pathways, or cortical networks in the brain, ultimately served by the substrate of the brain's neurological matrix (i.e. at the cellular and molecular level). Therefore, their understanding is closely linked to the practice of neuropsychology and cognitive neuroscience – two disciplines that broadly seek to understand how the structure and function of the brain relate to cognition and behaviour.
A neurocognitive deficit is a reduction or impairment of cognitive function in one of these areas, but particularly when physical changes can be seen to have occurred in the brain, such as aging related physiological changes or after neurological illness, mental illness, drug use, or brain injury.
A clinical neuropsychologist may specialise in using neuropsychological tests to detect and understand such deficits, and may be involved in the rehabilitation of an affected person. The discipline that studies neurocognitive deficits to infer normal psychological function is called cognitive neuropsychology.
Etymology
The term neurocognitive is a recent addition to the nosology of clinical Psychiatry and Psychology. It was rarely used before the publication of the DSM-5, which updated the psychiatric classification of disorders listed in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" chapter of the DSM-IV. Following the 2013 publication of the DSM-5, the use of the term "neurocognitive" − increased steadily.
Adding the prefix "neuro-" to the word "cognitive" is an example of pleonasm because analogous to expressions like "burning fire" and "black darkness", the prefix "neuro-" adds no further useful information to the term "cognitive". In the field of clinical neurology, clinicians continue using the simpler term "cognitive", due to the absence of evidence for human cognitive processes that do not involve the nervous system.
See also
Cognition
Cognitive neuropsychology
Cognitive neuroscience
Cognitive rehabilitation therapy
Neurology
Neuropsychology
Neuropsychological test
Neurotoxic
Brain fog
Hallucinogen persisting perception disorder
Depersonalization
Dementia
Mild cognitive impairment
Attention deficit hyperactivity disorder
Concussions in sport
References
Further reading
Green, K. J. (1998). Schizophrenia from a Neurocognitive Perspective. Boston, Allyn and Bacon.
Cognition
Cognitive neuroscience
Neuropsychology
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Psikhushka
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Psikhushka (; ) is a Russian ironic diminutive for psychiatric hospital. In Russia, the word entered everyday vocabulary. This word has been occasionally used in English, since the Soviet dissident movement and diaspora community in the West used the term. In the Soviet Union, psychiatric hospitals were often used by the authorities as prisons, in order to isolate political prisoners from the rest of society, discredit their ideas, and break them physically and mentally. As such, psikhushkas were considered a form of torture. The official explanation was that no sane person would be against socialism.
Psikhushkas were already in use by the end of the 1940s (see Alexander Esenin-Volpin), continuing into the Khrushchev Thaw period of the 1960s. On April 29, 1969, the head of the KGB, Yuri Andropov submitted to the Central Committee of CPSU a plan for the creation of a network of specialized "psychiatric hospitals" run by the KGB.
The official Soviet psychiatric science came up with the definition of sluggish schizophrenia, a special form of the illness that supposedly affects only the person's social behavior, with no trace on other traits: "most frequently, ideas about a struggle for truth and justice are formed by personalities with a paranoid structure," according to the Moscow Serbsky Institute professors (a quote from Vladimir Bukovsky's archives). Some of them had high rank in the MVD, such as the infamous Daniil Luntz, who was characterized by Viktor Nekipelov as "no better than the criminal doctors who performed inhuman experiments on the prisoners in Nazi concentration camps".
The sane individuals who were diagnosed as mentally ill were sent either to a regular psychiatric hospitals or, those deemed particularly dangerous, to special ones, run directly by the MVD. The treatment included various forms of restraint, electric shocks, a range of drugs (such as narcotics, tranquilizers, and insulin) that cause long-lasting side effects, and sometimes involved beatings. Nekipelov describes inhumane uses of medical procedures such as lumbar punctures.
Notable political prisoners of psikhushkas include poet Joseph Brodsky, dissidents Leonid Plyushch, Vladimir Bukovsky, Natalya Gorbanevskaya, Alexander Esenin-Volpin, Pyotr Grigorenko, Zhores Medvedev, Viktor Nekipelov, Valeriya Novodvorskaya, Natan Sharansky, Andrei Sinyavsky, and Anatoly Koryagin, politician Konstantin Päts, and whistle blower Larisa Arap.
References
Bibliography
Political abuse of psychiatry in the Soviet Union
Political repression in the Soviet Union
Persecution of dissidents in the Soviet Union
Psychiatric hospitals in Russia
Imprisonment and detention
Torture in Russia
Soviet phraseology
Pejorative terms
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Dual inheritance theory
|
Dual inheritance theory (DIT), also known as gene–culture coevolution or biocultural evolution, was developed in the 1960s through early 1980s to explain how human behavior is a product of two different and interacting evolutionary processes: genetic evolution and cultural evolution. Genes and culture continually interact in a feedback loop: changes in genes can lead to changes in culture which can then influence genetic selection, and vice versa. One of the theory's central claims is that culture evolves partly through a Darwinian selection process, which dual inheritance theorists often describe by analogy to genetic evolution.
'Culture', in this context, is defined as 'socially learned behavior', and 'social learning' is defined as copying behaviors observed in others or acquiring behaviors through being taught by others. Most of the modelling done in the field relies on the first dynamic (copying), though it can be extended to teaching. Social learning, at its simplest, involves blind copying of behaviors from a model (someone observed behaving), though it is also understood to have many potential biases, including success bias (copying from those who are perceived to be better off), status bias (copying from those with higher status), homophily (copying from those most like ourselves), conformist bias (disproportionately picking up behaviors that more people are performing), etc. Understanding social learning is a system of pattern replication, and understanding that there are different rates of survival for different socially learned cultural variants, this sets up, by definition, an evolutionary structure: cultural evolution.
Because genetic evolution is relatively well understood, most of DIT examines cultural evolution and the interactions between cultural evolution and genetic evolution.
Theoretical basis
DIT holds that genetic and cultural evolution interacted in the evolution of Homo sapiens. DIT recognizes that the natural selection of genotypes is an important component of the evolution of human behavior and that cultural traits can be constrained by genetic imperatives. However, DIT also recognizes that genetic evolution has endowed the human species with a parallel evolutionary process of cultural evolution. DIT makes three main claims:
Culture capacities are adaptations
The human capacity to store and transmit culture arose from genetically evolved psychological mechanisms. This implies that at some point during the evolution of the human species a type of social learning leading to cumulative cultural evolution was evolutionarily advantageous.
Culture evolves
Social learning processes give rise to cultural evolution. Cultural traits are transmitted differently from genetic traits and, therefore, result in different population-level effects on behavioral variation.
Genes and culture co-evolve
Cultural traits alter the social and physical environments under which genetic selection operates. For example, the cultural adoptions of agriculture and dairying have, in humans, caused genetic selection for the traits to digest starch and lactose, respectively. As another example, it is likely that once culture became adaptive, genetic selection caused a refinement of the cognitive architecture that stores and transmits cultural information. This refinement may have further influenced the way culture is stored and the biases that govern its transmission.
DIT also predicts that, under certain situations, cultural evolution may select for traits that are genetically maladaptive. An example of this is the demographic transition, which describes the fall of birth rates within industrialized societies. Dual inheritance theorists hypothesize that the demographic transition may be a result of a prestige bias, where individuals that forgo reproduction to gain more influence in industrial societies are more likely to be chosen as cultural models.
View of culture
People have defined the word "culture" to describe a large set of different phenomena. A definition that sums up what is meant by "culture" in DIT is:
This view of culture emphasizes population thinking by focusing on the process by which culture is generated and maintained. It also views culture as a dynamic property of individuals, as opposed to a view of culture as a superorganic entity to which individuals must conform. This view's main advantage is that it connects individual-level processes to population-level outcomes.
Genetic influence on cultural evolution
Genes affect cultural evolution via psychological predispositions on cultural learning. Genes encode much of the information needed to form the human brain. Genes constrain the brain's structure and, hence, the ability of the brain to acquire and store culture. Genes may also endow individuals with certain types of transmission bias (described below).
Cultural influences on genetic evolution
Culture can profoundly influence gene frequencies in a population.
Lactase persistence
One of the best known examples is the prevalence of the genotype for adult lactose absorption in human populations, such as Northern Europeans and some African societies, with a long history of raising cattle for milk. Until around 7,500 years ago, lactase production stopped shortly after weaning, and in societies which did not develop dairying, such as East Asians and Amerindians, this is still true today. In areas with lactase persistence, it is believed that by domesticating animals, a source of milk became available while an adult and thus strong selection for lactase persistence could occur; in a Scandinavian population, the estimated selection coefficient was 0.09-0.19. This implies that the cultural practice of raising cattle first for meat and later for milk led to selection for genetic traits for lactose digestion. Recently, analysis of natural selection on the human genome suggests that civilization has accelerated genetic change in humans over the past 10,000 years.
Food processing
Culture has driven changes to the human digestive systems making many digestive organs, such as teeth or stomach, smaller than expected for primates of a similar size, and has been attributed to one of the reasons why humans have such large brains compared to other great apes. This is due to food processing. Early examples of food processing include pounding, marinating and most notably cooking. Pounding meat breaks down the muscle fibres, hence taking away some of the job from the mouth, teeth and jaw. Marinating emulates the action of the stomach with high acid levels. Cooking partially breaks down food making it more easily digestible. Food enters the body effectively partly digested, and as such food processing reduces the work that the digestive system has to do. This means that there is selection for smaller digestive organs as the tissue is energetically expensive, those with smaller digestive organs can process their food but at a lower energetic cost than those with larger organs. Cooking is notable because the energy available from food increases when cooked and this also means less time is spent looking for food.
Humans living on cooked diets spend only a fraction of their day chewing compared to other extant primates living on raw diets. American girls and boys spent on average 7 to 8 percent of their day chewing respectively (1.68 to 1.92 hours per day), compared to chimpanzees, who spend more than 6 hours a day chewing. This frees up time which can be used for hunting. A raw diet means hunting is constrained since time spent hunting is time not spent eating and chewing plant material, but cooking reduces the time required to get the day's energy requirements, allowing for more subsistence activities. Digestibility of cooked carbohydrates is approximately on average 30% higher than digestibility of non-cooked carbohydrates. This increased energy intake, more free time and savings made on tissue used in the digestive system allowed for the selection of genes for larger brain size.
Despite its benefits, brain tissue requires a large amount of calories, hence a main constraint in selection for larger brains is calorie intake. A greater calorie intake can support greater quantities of brain tissue. This is argued to explain why human brains can be much larger than other apes, since humans are the only ape to engage in food processing. The cooking of food has influenced genes to the extent that, research suggests, humans cannot live without cooking. A study on 513 individuals consuming long-term raw diets found that as the percentage of their diet which was made up of raw food and/or the length they had been on a diet of raw food increased, their BMI decreased. This is despite access to many non-thermal processing, like grinding, pounding or heating to 48 °C. (118 °F). With approximately 86 billion neurons in the human brain and 60–70 kg body mass, an exclusively raw diet close to that of what extant primates have would be not viable as, when modelled, it is argued that it would require an infeasible level of more than nine hours of feeding every day. However, this is contested, with alternative modelling showing enough calories could be obtained within 5–6 hours per day. Some scientists and anthropologists point to evidence that brain size in the Homo lineage started to increase well before the advent of cooking due to increased consumption of meat and that basic food processing (slicing) accounts for the size reduction in organs related to chewing. Cornélio et al. argues that improving cooperative abilities and a varying of diet to more meat and seeds improved foraging and hunting efficiency. It is this that allowed for the brain expansion, independent of cooking which they argue came much later, a consequence from the complex cognition that developed. Yet this is still an example of a cultural shift in diet and the resulting genetic evolution. Further criticism comes from the controversy of the archaeological evidence available. Some claim there is a lack of evidence of fire control when brain sizes first started expanding. Wrangham argues that anatomical evidence around the time of the origin of Homo erectus (1.8 million years ago), indicates that the control of fire and hence cooking occurred. At this time, the largest reductions in tooth size in the entirety of human evolution occurred, indicating that softer foods became prevalent in the diet. Also at this time was a narrowing of the pelvis indicating a smaller gut and also there is evidence that there was a loss of the ability to climb which Wrangham argues indicates the control of fire, since sleeping on the ground needs fire to ward off predators. The proposed increases in brain size from food processing will have led to a greater mental capacity for further cultural innovation in food processing which will have increased digestive efficiency further providing more energy for further gains in brain size. This positive feedback loop is argued to have led to the rapid brain size increases seen in the Homo lineage.
Mechanisms of cultural evolution
In DIT, the evolution and maintenance of cultures is described by five major mechanisms: natural selection of cultural variants, random variation, cultural drift, guided variation and transmission bias.
Natural selection
Differences between cultural phenomena result in differential rates of their spread; similarly, cultural differences among individuals can lead to differential survival and reproduction rates of individuals. The patterns of this selective process depend on transmission biases and can result in behavior that is more adaptive to a given environment.
Random variation
Random variation arises from errors in the learning, display or recall of cultural information, and is roughly analogous to the process of mutation in genetic evolution.
Cultural drift
Cultural drift is a process roughly analogous to genetic drift in evolutionary biology. In cultural drift, the frequency of cultural traits in a population may be subject to random fluctuations due to chance variations in which traits are observed and transmitted (sometimes called "sampling error"). These fluctuations might cause cultural variants to disappear from a population. This effect should be especially strong in small populations. A model by Hahn and Bentley shows that cultural drift gives a reasonably good approximation to changes in the popularity of American baby names. Drift processes have also been suggested to explain changes in archaeological pottery and technology patent applications. Changes in the songs of song birds are also thought to arise from drift processes, where distinct dialects in different groups occur due to errors in songbird singing and acquisition by successive generations. Cultural drift is also observed in an early computer model of cultural evolution.
Guided variation
Cultural traits may be gained in a population through the process of individual learning. Once an individual learns a novel trait, it can be transmitted to other members of the population. The process of guided variation depends on an adaptive standard that determines what cultural variants are learned.
Biased transmission
Understanding the different ways that culture traits can be transmitted between individuals has been an important part of DIT research since the 1970s. Transmission biases occur when some cultural variants are favored over others during the process of cultural transmission. Boyd and Richerson (1985) defined and analytically modeled a number of possible transmission biases. The list of biases has been refined over the years, especially by Henrich and McElreath.
Content bias
Content biases result from situations where some aspect of a cultural variant's content makes them more likely to be adopted. Content biases can result from genetic preferences, preferences determined by existing cultural traits, or a combination of the two. For example, food preferences can result from genetic preferences for sugary or fatty foods and socially-learned eating practices and taboos. Content biases are sometimes called "direct biases."
Context bias
Context biases result from individuals using clues about the social structure of their population to determine what cultural variants to adopt. This determination is made without reference to the content of the variant. There are two major categories of context biases: model-based biases, and frequency-dependent biases.
Model-based biases
Model-based biases result when an individual is biased to choose a particular "cultural model" to imitate. There are four major categories of model-based biases: prestige bias, skill bias, success bias, and similarity bias. A "prestige bias" results when individuals are more likely to imitate cultural models that are seen as having more prestige. A measure of prestige could be the amount of deference shown to a potential cultural model by other individuals. A "skill bias" results when individuals can directly observe different cultural models performing a learned skill and are more likely to imitate cultural models that perform better at the specific skill. A "success bias" results from individuals preferentially imitating cultural models that they determine are most generally successful (as opposed to successful at a specific skill as in the skill bias.) A "similarity bias" results when individuals are more likely to imitate cultural models that are perceived as being similar to the individual based on specific traits.
Frequency-dependent biases
Frequency-dependent biases result when an individual is biased to choose particular cultural variants based on their perceived frequency in the population. The most explored frequency-dependent bias is the "conformity bias." Conformity biases result when individuals attempt to copy the mean or the mode cultural variant in the population. Another possible frequency dependent bias is the "rarity bias." The rarity bias results when individuals preferentially choose cultural variants that are less common in the population. The rarity bias is also sometimes called a "nonconformist" or "anti-conformist" bias.
Social learning and cumulative cultural evolution
In DIT, the evolution of culture is dependent on the evolution of social learning. Analytic models show that social learning becomes evolutionarily beneficial when the environment changes with enough frequency that genetic inheritance can not track the changes, but not fast enough that individual learning is more efficient. For environments that have very little variability, social learning is not needed since genes can adapt fast enough to the changes that occur, and innate behaviour is able to deal with the constant environment. In fast changing environments cultural learning would not be useful because what the previous generation knew is now outdated and will provide no benefit in the changed environment, and hence individual learning is more beneficial. It is only in the moderately changing environment where cultural learning becomes useful since each generation shares a mostly similar environment but genes have insufficient time to change to changes in the environment. While other species have social learning, and thus some level of culture, only humans, some birds and chimpanzees are known to have cumulative culture. Boyd and Richerson argue that the evolution of cumulative culture depends on observational learning and is uncommon in other species because it is ineffective when it is rare in a population. They propose that the environmental changes occurring in the Pleistocene may have provided the right environmental conditions. Michael Tomasello argues that cumulative cultural evolution results from a ratchet effect that began when humans developed the cognitive architecture to understand others as mental agents. Furthermore, Tomasello proposed in the 80s that there are some disparities between the observational learning mechanisms found in humans and great apes - which go some way to explain the observable difference between great ape traditions and human types of culture (see Emulation (observational learning)).
Cultural group selection
Although group selection is commonly thought to be nonexistent or unimportant in genetic evolution, DIT predicts that, due to the nature of cultural inheritance, it may be an important force in cultural evolution. Group selection occurs in cultural evolution because conformist biases make it difficult for novel cultural traits to spread through a population (see above section on transmission biases). Conformist bias also helps maintain variation between groups. These two properties, rare in genetic transmission, are necessary for group selection to operate. Based on an earlier model by Cavalli-Sforza and Feldman, Boyd and Richerson show that conformist biases are almost inevitable when traits spread through social learning, implying that group selection is common in cultural evolution. Analysis of small groups in New Guinea imply that cultural group selection might be a good explanation for slowly changing aspects of social structure, but not for rapidly changing fads. The ability of cultural evolution to maintain intergroup diversity is what allows for the study of cultural phylogenetics.
Historical development
In 1876, Friedrich Engels wrote a manuscript titled The Part Played by Labour in the Transition from Ape to Man, accredited as a founding document of DIT; “The approach to gene-culture coevolution first developed by Engels and developed later on by anthropologists…” is described by Stephen Jay Gould as “…the best nineteenth-century case for gene-culture coevolution.” The idea that human cultures undergo a similar evolutionary process as genetic evolution also goes back to Darwin. In the 1960s, Donald T. Campbell published some of the first theoretical work that adapted principles of evolutionary theory to the evolution of cultures. In 1976, two developments in cultural evolutionary theory set the stage for DIT. In that year Richard Dawkins's The Selfish Gene introduced ideas of cultural evolution to a popular audience. Although one of the best-selling science books of all time, because of its lack of mathematical rigor, it had little effect on the development of DIT. Also in 1976, geneticists Marcus Feldman and Luigi Luca Cavalli-Sforza published the first dynamic models of gene–culture coevolution. These models were to form the basis for subsequent work on DIT, heralded by the publication of three seminal books in the 1980s.
The first was Charles Lumsden and E.O. Wilson's Genes, Mind and Culture. This book outlined a series of mathematical models of how genetic evolution might favor the selection of cultural traits and how cultural traits might, in turn, affect the speed of genetic evolution. While it was the first book published describing how genes and culture might coevolve, it had relatively little effect on the further development of DIT. Some critics felt that their models depended too heavily on genetic mechanisms at the expense of cultural mechanisms. Controversy surrounding Wilson's sociobiological theories may also have decreased the lasting effect of this book.
The second 1981 book was Cavalli-Sforza and Feldman's Cultural Transmission and Evolution: A Quantitative Approach. Borrowing heavily from population genetics and epidemiology, this book built a mathematical theory concerning the spread of cultural traits. It describes the evolutionary implications of vertical transmission, passing cultural traits from parents to offspring; oblique transmission, passing cultural traits from any member of an older generation to a younger generation; and horizontal transmission, passing traits between members of the same population.
The next significant DIT publication was Robert Boyd and Peter Richerson's 1985 Culture and the Evolutionary Process. This book presents the now-standard mathematical models of the evolution of social learning under different environmental conditions, the population effects of social learning, various forces of selection on cultural learning rules, different forms of biased transmission and their population-level effects, and conflicts between cultural and genetic evolution. The book's conclusion also outlined areas for future research that are still relevant today.
Current and future research
In their 1985 book, Boyd and Richerson outlined an agenda for future DIT research. This agenda, outlined below, called for the development of both theoretical models and empirical research. DIT has since built a rich tradition of theoretical models over the past two decades. However, there has not been a comparable level of empirical work.
In a 2006 interview Harvard biologist E. O. Wilson expressed disappointment at the little attention afforded to DIT:
Kevin Laland and Gillian Ruth Brown attribute this lack of attention to DIT's heavy reliance on formal modeling.
Economist Herbert Gintis disagrees with this critique, citing empirical work as well as more recent work using techniques from behavioral economics. These behavioral economic techniques have been adapted to test predictions of cultural evolutionary models in laboratory settings as well as studying differences in cooperation in fifteen small-scale societies in the field.
Since one of the goals of DIT is to explain the distribution of human cultural traits, ethnographic and ethnologic techniques may also be useful for testing hypothesis stemming from DIT. Although findings from traditional ethnologic studies have been used to buttress DIT arguments, thus far there have been little ethnographic fieldwork designed to explicitly test these hypotheses.
Herb Gintis has named DIT one of the two major conceptual theories with potential for unifying the behavioral sciences, including economics, biology, anthropology, sociology, psychology and political science. Because it addresses both the genetic and cultural components of human inheritance, Gintis sees DIT models as providing the best explanations for the ultimate cause of human behavior and the best paradigm for integrating those disciplines with evolutionary theory. In a review of competing evolutionary perspectives on human behavior, Laland and Brown see DIT as the best candidate for uniting the other evolutionary perspectives under one theoretical umbrella.
Relation to other fields
Sociology and cultural anthropology
Two major topics of study in both sociology and cultural anthropology are human cultures and cultural variation.
However, Dual Inheritance theorists charge that both disciplines too often treat culture as a static superorganic entity that dictates human behavior. Cultures are defined by a suite of common traits shared by a large group of people. DIT theorists argue that this doesn't sufficiently explain variation in cultural traits at the individual level. By contrast, DIT models human culture at the individual level and views culture as the result of a dynamic evolutionary process at the population level.
Human sociobiology and evolutionary psychology
Evolutionary psychologists study the evolved architecture of the human mind. They see it as composed of many different programs that process information, each with assumptions and procedures that were specialized by natural selection to solve a different adaptive problem faced by our hunter-gatherer ancestors (e.g., choosing mates, hunting, avoiding predators, cooperating, using aggression). These evolved programs contain content-rich assumptions about how the world and other people work. When ideas are passed from mind to mind, they are changed by these evolved inference systems (much like messages get changed in a game of telephone). But the changes are not usually random. Evolved programs add and subtract information, reshaping the ideas in ways that make them more "intuitive", more memorable, and more attention-grabbing. In other words, "memes" (ideas) are not precisely like genes. Genes are normally copied faithfully as they are replicated, but ideas normally are not. It's not just that ideas mutate every once in a while, like genes do. Ideas are transformed every time they are passed from mind to mind, because the sender's message is being interpreted by evolved inference systems in the receiver. It is useful for some applications to note, however, that there are ways to pass ideas which are more resilient and involve substantially less mutation, such as by mass distribution of printed media.
There is no necessary contradiction between evolutionary psychology and DIT, but evolutionary psychologists argue that the psychology implicit in many DIT models is too simple; evolved programs have a rich inferential structure not captured by the idea of a "content bias". They also argue that some of the phenomena DIT models attribute to cultural evolution are cases of "evoked culture"—situations in which different evolved programs are activated in different places, in response to cues in the environment.
Sociobiologists try to understand how maximizing genetic fitness, in either the modern era or past environments, can explain human behavior. When faced with a trait that seems maladaptive, some sociobiologists try to determine how the trait actually increases genetic fitness (maybe through kin selection or by speculating about early evolutionary environments). Dual inheritance theorists, in contrast, will consider a variety of genetic and cultural processes in addition to natural selection on genes.
Human behavioral ecology
Human behavioral ecology (HBE) and DIT have a similar relationship to what ecology and evolutionary biology have in the biological sciences. HBE is more concerned about ecological process and DIT more focused on historical process. One difference is that human behavioral ecologists often assume that culture is a system that produces the most adaptive outcome in a given environment. This implies that similar behavioral traditions should be found in similar environments. However, this is not always the case. A study of African cultures showed that cultural history was a better predictor of cultural traits than local ecological conditions.
Memetics
Memetics, which comes from the meme idea described in Dawkins's The Selfish Gene, is similar to DIT in that it treats culture as an evolutionary process that is distinct from genetic transmission. However, there are some philosophical differences between memetics and DIT. One difference is that memetics' focus is on the selection potential of discrete replicators (memes), where DIT allows for transmission of both non-replicators and non-discrete cultural variants. DIT does not assume that replicators are necessary for cumulative adaptive evolution. DIT also more strongly emphasizes the role of genetic inheritance in shaping the capacity for cultural evolution. But perhaps the biggest difference is a difference in academic lineage. Memetics as a label is more influential in popular culture than in academia. Critics of memetics argue that it is lacking in empirical support or is conceptually ill-founded, and question whether there is hope for the memetic research program succeeding. Proponents point out that many cultural traits are discrete, and that many existing models of cultural inheritance assume discrete cultural units, and hence involve memes.
Criticisms
Psychologist Liane Gabora has criticised DIT. She argues that traits that are not transmitted by way of a self-assembly code (as in genetic evolution) is misleading, because this second use does not capture the algorithmic structure that makes an inheritance system require a particular kind of mathematical framework.
Other criticisms of the effort to frame culture in tandem with evolution have been leveled by Richard Lewontin, Niles Eldredge, and Stuart Kauffman.
See also
References
Further reading
Books
Lumsden, C. J. and E. O. Wilson. 1981. Genes, Mind, and Culture: The Coevolutionary Process. Cambridge, Massachusetts: Harvard University Press.
Cavalli-Sforza, L. L. and M. Feldman. 1981. Cultural Transmission and Evolution: A Quantitative Approach. Princeton, New Jersey: Princeton University Press.
Durham, W. H. 1991. Coevolution: Genes, Culture and Human Diversity. Stanford, California: Stanford University Press.
Shennan, S. J. 2002. Genes, Memes and Human History: Darwinian Archaeology and Cultural Evolution. London: Thames and Hudson.
Boyd, R. and P. J. Richerson. 2005. The Origin and Evolution of Cultures. Oxford: Oxford University Press.
Laland, K.H. 2017. Darwin's Unfinished Symphony: How Culture Made the Human Mind. Princeton: Princeton University Press.
Reviews
Smith, E. A. 1999. Three styles in the evolutionary analysis of human behavior. In L. Cronk, N. Chagnon, and W. Irons, (Eds.) Adaptation and Human Behavior: An Anthropological Perspective New York: Aldine de Gruyter.
Bentley, R.A., C. Lipo, H.D.G. Maschner and B. Marler 2007. Darwinian Archaeologies. In R.A. Bentley, H.D.G. Maschner & C. Chippendale (Eds.) Handbook of Archaeological Theories. Lanham (MD): AltaMira Press.
Journal articles
External links
Current DIT researchers
Rob Boyd, Department of Anthropology, UCLA
Marcus Feldman , Department of Biological Sciences, Stanford
Joe Henrich, Departments of Psychology and Economics, University of British Columbia
Richard McElreath, Anthropology Department, UC Davis
Peter J. Richerson, Department of Environmental Science and Policy, UC Davis
Related researchers
Liane Gabora , Department of Psychology, University of British Columbia
Russell Gray Max Planck Institute for the Science of Human History, Jena, Germany
Herb Gintis , Emeritus Professor of Economics, University of Massachusetts & Santa Fe Institute
Kevin Laland , School of Biology, University of St. Andrews
Ruth Mace, Department of Anthropology, University College London
Alex Mesoudi Human Biological and Cultural Evolution Group, University of Exeter, UK
Michael Tomasello, Department of Developmental and Comparative Psychology, Max Planck Institute for Evolutionary Anthropology
Peter Turchin Department of Ecology and Evolutionary Biology, University of Connecticut
Mark Collard, Department of Archaeology, Simon Fraser University, and Department of Archaeology, University of Aberdeen
Anthropology
Behavioural genetics
Cultural anthropology
Human evolution
Population genetics
Sociobiology
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Your Erroneous Zones
|
Your Erroneous Zones is the first self-help book written by Wayne Dyer and first issued by Funk & Wagnalls publishers in April 1976.
It is one of the best-selling books of all time, with an estimated 100 million copies sold. The book spent 64 weeks on The New York Times bestseller list through November 13, 1977, including a spot at number one on the week of May 8, 1977.
Contents
Chapter I. Taking Charge of Yourself.
In this Chapter Dyer takes note of the brevity of life. He asserts that feelings are reactions you choose to have. He points out that learning not to be unhappy is a tough assignment as habits can only be changed by patience and persistence. Choice is our great power. He introduces for the first time the concept of immobilisation and gives a checklist of instances. Living in the present moment (a habit) is all important.
Chapter II. Self Love.
The sub heading of this Chapter gives a basic idea/attitude upon which the whole of this books message depends, our personal habitual feeling of self worth. "Love yourself, a lot". For effective living Dyer asserts that "Self love is (must become) a given".
"Under no circumstances is self hate better than Self Love"
Chapter III. You Do Not Need Their Approval
In this Chapter Dyer gives "Historical precedents for Approval seeking" and notes the "profusion of cultural approval seeking messages". Early Childhood, School, the Church, the Government, Popular Songs, Television Commercials are all dealt with. Dyer uses the phrase "Coaxing Approval Seeking down the stairs a step at a time" to describe the change in habit needed for us to more effectively deal with the hinderance of approval seeking.
Chapter IV Breaking Free From the Past.
In the sub heading of this chapter Dyer uses a phrase which gives the main thrust of the Chapter. "You are what you choose today, not what you have chosen before". He gives a list of 35 negative "I'ms" e.g "I'm poor at Mathematics". The Chapter continues with "How Those "I'ms got started". Another constant thread through this chapter and the rest of the book are the Neurotic Dividends of Erroneous Zones. The "I'm" circle of thought is illustrated. Strategies to rid oneself of this ineffective behaviour are listed, including eliminating one I'm for one day. Final thoughts highlight the great benefit of continuous learning and the only good I'm is "I'm - an I'm exorcist -and I like it".
Chapter V. The Useless Emotions- Guilt and Worry.
These emotions are classified as "useless" by Dyer. Dyer places them on a continuum. Guilt is useless in regard to changing past events, worry useless in regard to the outcome of future events. Dyer states that worrying which "immobilizes" us in the present is not to be confused with careful planning which is a rational and effective thing to do. The sources of our guilt and worry habits Dyer lists and they are similar in both cases. Parents, spouses, children, school, Church, eating, sex. As in other chapters Dyer list the pay offs for choosing these emotions. Strategies for eliminating these damaging emotions are given. Finally the critical worth of "present moment" living is restated as being the key to becoming more effective with regard to guilt and worry.
Chapter VI. Exploring the Unknown.
Dyer begins by noting how our early training makes us "safety experts", a big loss, as the mysterious is the source of all growth and excitement. Dyer urges us to create habits of openness to new experiences, avoiding rigidity, prejudice and "always having a plan". He then considers one of the constant and central themes of the whole book "Security: Internal and External Varieties". Fear of failure is next considered and the benefit of the effective habit of an internal sense of self worth is highlighted. As in other chapters Dyer list typical examples of this particular erroneous zone, supposed Psychological benefits and strategies to overcome it. Finally the great benefit to Humanity of the explorers and inventors is noted. An appropriate quote From Robert Frost is given.
Criticism
Psychotherapist Albert Ellis writes that Dyer's book Your Erroneous Zones is probably "the worst example" of plagiarism of Ellis's Rational Emotive Behavioral Therapy (REBT). In a 1985 letter to Dyer, Ellis claims that Dyer had participated in a workshop Ellis gave on REBT before Dyer published his book, in which Dyer appeared to understand REBT very well. Wayne Dyer probably had a fundamental understanding before continuing to explore this idea. Ellis adds that "300 or more people have voluntarily told me... that [the book] was clearly derived from REBT." Dyer never apologized or expressed any sense of wrongdoing. Ellis admonishes Dyer for unethically and unprofessionally not giving Ellis credit as the book's primary source, but expressed overall gratitude for Dyer's work, writing: "Your Erroneous Zones is a good book, ... it has helped a great number of people, and ... it outlines the main principles of REBT quite well,... with great simplicity and clarity."
Dyer's book Your Erroneous Zones makes a minor mention of Albert Ellis on page 148.
References
Self-help books
1976 non-fiction books
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Self-acceptance
|
Self-acceptance is acceptance of self.
Definition
Self-acceptance can be defined as:
the awareness of one's strengths and weaknesses,
the realistic (yet subjective) appraisal of one's talents, capabilities, and general worth, and,
feelings of satisfaction with one's self despite deficiencies and regardless of past behaviors and choices.
According to Shepard, self-acceptance is an individual's satisfaction or happiness with oneself, and is thought to be necessary for good mental health. Self-acceptance involves self-understanding, a realistic, albeit subjective, awareness of one's strengths and weaknesses. It results in an individual's feeling about oneself, that they are of "unique worth".
Albert Ellis advocated the importance of accepting yourself just because you are alive, human and unique—and not giving yourself a global rating, or being influenced by what others think of you.
In clinical psychology and positive psychology, self-acceptance is considered the prerequisite for change to occur. It can be achieved by stopping criticizing and solving the defects of one's self, and then accepting them to be existing within one's self. That is, tolerating oneself to be imperfect in some parts.
Some distinguish between conditional and unconditional self-acceptance.
Self-acceptance is one of the six factors in Carol D. Ryff's structure for eudaimonic well-being.
Qualities
A person who scores high on self-acceptance:
has a positive self-attitude,
acknowledges and accepts all aspects of themselves (including the good and bad),
is not self-critical or confused about their identity, and,
does not wish they were any different from who they already are.
Past and current views in psychology
In the past, the practice of self-acceptance was reproved by the Greeks. However, the need to know about and understand "the self" eventually became an important, underlying point in several psychological theories, such as:
Jahoda's work on mental health,
Carl Rogers' Theory of Personality,
Gordon Allport's Eight Stages of Self (Proprium) Development,
Maslow's Hierarchy of Needs under the "self-actualization" category,
Albert Ellis' Rational emotive behavioral therapy
In addition to that, the life-span theories of Erikson and Neugarten mention the importance of self-acceptance including one's past life, and Carl Jung's process of individuation also emphasizes coming to terms with the dark side of one's self, or "the shadow".
Relation to positive psychology
With respect to positive psychology, self-acceptance, as a component of eudaimonic well-being (EWB), is an indicator and a measure of psychological well-being. For instance, Alfred Adler, founder of individual psychology, observed that people who thought of themselves as inferior also observed a depreciation of others.
Psychological benefits
Some psychological benefits of self-acceptance include mood regulation, a decrease in depressive symptoms, and an increase in positive emotions.
An example of this can be seen in a 2014 study that looked at affective profiles. The results yielded suggest that individuals categorized as self-fulfilling (as compared to the other profiles) tended to score higher on all the factors of Ryff's eudaimonic well-being dimensions (self-acceptance included).
In addition to that, self-acceptance (and environmental mastery) specifically and significantly predicted harmony in life across all affective profiles.
Other psychological benefits include:
a heightened sense of freedom,
a decrease in fear of failure,
an increase in self-worth,
an increase in independence (autonomy),
an increase in self-esteem,
less desire to win the approval of others,
less self-critique and more self-kindness when mistakes occur,
more desire to live life for one's self (and not others), and,
the ability to take more risks without worrying about the consequences.
Self-acceptance is also thought to be necessary for good mental health.
Physical benefits
In addition to psychological benefits, self-acceptance may have physical benefits as well. For example, the results of a 2008 study propose that older women with higher levels of environmental mastery, positive relations with others, and self-acceptance showed lower levels of glycosylated hemoglobin, which is a marker for glucose levels/insulin resistance.
See also
Self-compassion
Self-esteem
Self-love
Unconditional positive regard
References
Self
Spiritual faculties
Mindfulness movement
Positive psychology
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Disordered eating
|
Disordered eating describes a variety of abnormal eating behaviors that, by themselves, do not warrant diagnosis of an eating disorder.
Disordered eating includes behaviors that are common features of eating disorders, such as:
Chronic restrained eating.
Compulsive eating.
Binge eating, with associated loss of control.
Self-induced vomiting.
Disordered eating also includes behaviors that are not characteristic of a specific eating disorder, such as:
Irregular, chaotic eating patterns.
Ignoring physical feelings of hunger and satiety (fullness).
Use of diet pills.
Emotional eating.
Night eating.
Secretive food concocting: the consumption of embarrassing food combinations, such as mashed potatoes mixed with sandwich cookies. See also Food craving § Pregnancy and Nocturnal sleep-related eating disorder § Symptoms and behaviors.
Potential causes of disordered eating
Disordered eating can represent a change in eating patterns caused by other mental disorders (e.g. clinical depression), or by factors that are generally considered to be unrelated to mental disorders (e.g. extreme homesickness).
Certain factors among adolescents tend to be associated with disordered eating, including perceived pressure from parents and peers, nuclear family dynamic, body mass index, negative affect (mood), self-esteem, perfectionism, drug use, and participation in sports that focus on leanness. These factors are similar among boys and girls alike. However, the reported incidence rates of disordered eating are consistently and significantly higher in female than male participants. 61% of females and 28% of males reported disordered eating behaviors in a study of over 1600 adolescents.
Nuclear family environment
The nuclear family dynamic of an adolescent plays a large part in the formation of their psychological, and thus behavioral, development. A research article published in the Journal of Adolescence concluded that, “…while families do not appear to play a primary casual role in eating pathology, dysfunctional family environments and unhealthy parenting can affect the genesis and maintenance of disordered eating.”
One study explored the connection between the disordered eating patterns of adolescents and the poor socioemotional coping mechanisms of guardians with mental disorders. It was found that in homes of parents with mental health issues (such as depression or anxiety), the children living in these environments self-reported experiencing stressful home environments, parental withdrawal, rejection, unfulfilled emotional needs, or over-involvement from their guardians. It was hypothesized that this was directly related to adolescent study participants also reporting poor emotional awareness, expression, and regulation in relation to internalized/externalized eating disordered habits. Parental anxiety/depression could not be directly linked to disordered eating, but could be linked to the development of poor coping skills that can lead to disordered eating behaviors.
Another study specifically investigated whether a parental's eating disorder could predict disordered eating in their children. It was found that rates of eating disorder appearances in children with either parent having a history of an eating disorder were much higher than those with parents without an eating disorder. Reported disordered eating peaked between ages 15 and 17 with the risk of eating disorder occurrences in females 12.7 times greater than of that in males. This is, "of particular interest as it has been shown that maternal ED [eating disorders] predict disordered eating behaviour in their daughters." This suggests that poor eating habits result as a coping mechanism for other direct issues presented by an unstable home environment.
Social stresses
Additional stress from outside the home environment influence disordered eating characteristics. Social stresses from peer environments, such as feeling out of place or discriminated against, has been shown to increase feelings of body shame and social anxiety in studies of minority groups that lead to a prevalence of disordered eating.
A study published in the International Journal of Eating Disorders used data from the Massachusetts Youth Risk Behavior Surveys from 1999 to 2013 to examine how disordered eating has trended in heterosexual versus LGB (lesbian, gay, bisexual) youth. The data from over 26,000 surveys investigated the practices of purging, fasting, and using diet pills. It was found that, "sexual minority youth report disproportionately higher prevalence of disordered eating compared to heterosexual peers: up to 1 in 4 sexual minority youth report…patterns of disordered eating…" In addition, the gap between the number of LGBT females and heterosexual females controlling weight in unhealthy ways has continued to widen.
The concept this study proposed to explain this disparity comes from the minority stress theory. This states that unhealthy behaviors are directly related to the distal stress, or social stress, that minorities experience. These stressors could include rejection or pressure by peers, and physical, mental, and emotional harassment.
A study published in Psychology of Women Quarterly explored the connection between social anxiety stresses and eating disordered habits more in depth in women in the LGBTQ community who were also racial minorities. Over 450 women ranked their interactions with everyday discrimination, their LGBTQ identity, social anxiety, their objectified body consciousness, and an eating disorder inventory diagnostic scale. The findings of the compilation of survey responses indicated that increased discrimination led to proximal minority stress, leading to feelings of social anxiety and body shame, which could be directly associated with binge eating, bulimia, and other signs of disordered eating. It has also been suggested that being a “double” or “triple” minority who experiences discrimination towards multiple characteristics contributes to more intense psychological distress and maladaptive coping mechanisms.
Athletic influences
Disordered eating among athletes, particularly female athletes, has been the subject of much research. In one study, women with disordered eating were 3.6 times as likely to have an eating disorder if they were athletes. In addition, female collegiate athletes who compete in heavily body conscious sports like gymnastics, swimming, or diving are shown to be more at risk for developing an eating disorder. This is a result of the engagement in sports where weekly repeated weigh-ins are standard, and usually required by coaches.
A study published in Eating Behaviors examined the pressure of mandated weigh-ins on female collegiate athletes and how that pressure was dealt with in terms of weight management. After analyzing over 400 survey responses, it was found that athletes reported increased uses of diet pills/laxatives, consuming less calories than needed for their sport, and following nutrition information from unqualified sources. 75% of the weighed athletes reported using a weight-management method such as restricting food intake, increasing exercise, eating low fat foods, taking laxatives, vomiting, and other.
These habits were found to be worse in athletes that were weighed in front of their peers than those weighed in private. In addition, especially in gymnasts, preoccupation and anxiety about gaining weight and being weighed, and viewing food as the enemy were prevalent mindsets. This harmful mindset continued even after the gymnasts were retired from their sport: "Although retired, these gymnasts were still afraid to step onto a scale, were anxious about gaining weight…suggesting that the negative effects of being weighed can linger…[and] suggest[ing] that the weight/ fitness requirements acted as a socio-cultural pressure that would substantially increase the women’s risk of developing an eating disorder in the future."
Disordered eating, along with amenorrhea and bone demineralization, form what clinicians refer to as the female athletic triad, or FAT. In contribution to these eating disorders that these female athletes develop, Results in the lack of nutrition. This can lead to the loss of several or more consecutive periods which then leads to calcium and bone loss, putting the athlete at great risk of fracturing bones and damaging tissues. Each of these conditions is a medical concern as they create serious health risks that may be life-threatening to the individual. While any female athlete can develop the triad, adolescent girls are considered most at risk because of the active biological changes and growth spurts that they experience, rapidly changing life circumstances that are observed within the teenage years, and peer and social pressures.
Social media
Researchers have said the most pervasive and influential factor controlling body image perception is the mass media. One study examined the impact of celebrity and peer Instagram images on women's body image as, “comparisons will be most readily made with individuals who are perceived as being similar” to the target as there is more of a relationship between the two parties. The participants in this study, 138 female undergraduate students ages 18–30, were shown 15 images each of attractive celebrities, attractive unknown peers, and travel destinations. The participant's reactions were observed and visual scales were used to measure mood and dissatisfaction before and after viewing the images. The findings of this experiment determined that negative mood and body dissatisfaction rankings were greater after being exposed to the celebrity and peer images, with no difference between celebrity versus peer images. The media is especially dangerous for females at risk for developing body image issues, and disordered eating, because the sheer number of possible comparisons become larger.
See also
Night eating syndrome
Overeaters Anonymous
References
Eating disorders
Symptoms and signs of mental disorders
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Differential psychology
|
Differential psychology studies the ways in which individuals differ in their behavior and the processes that underlie it. It is a discipline that develops classifications (taxonomies) of psychological individual differences. This is distinguished from other aspects of psychology in that, although psychology is ostensibly a study of individuals, modern psychologists often study groups, or attempt to discover general psychological processes that apply to all individuals. This particular area of psychology was first named and still retains the name of "differential psychology" by William Stern in his 1900 book "Über Psychologie der individuellen Differenzen" (On the Psychology of Individual Differences).
While prominent psychologists, including Stern, have been widely credited for the concept of differential psychology, historical records show that it was Charles Darwin (1859) who first spurred the scientific interest in the study of individual differences. The interest was further pursued by half-cousin Francis Galton in his attempt to quantify individual differences among people.
For example, in evaluating the effectiveness of a new therapy, the mean performance of the therapy in one treatment group might be compared to the mean effectiveness of a placebo (or a well-known therapy) in a second, control group. In this context, differences between individuals in their reaction to the experimental and control manipulations are actually treated as errors rather than as interesting phenomena to study. This approach is applied because psychological research depends upon statistical controls that are only defined upon groups of people.
Importance of individual differences
Importantly, individuals can also differ not only in their current state, but in the magnitude or even direction of response to a given stimulus. Such phenomena, often explained in terms of inverted-U response curves, place differential psychology at an important location in such endeavours as personalized medicine, in which diagnoses are customised for an individual's response profile.
Areas of study
Individual differences research typically includes personality, temperament (neuro-chemically based behavioural traits), motivation, intelligence, ability, IQ, interests, values, self-concept, self-efficacy, and self-esteem (to name just a few). Although the United States has seen a decrease in individual differences research since the 1960s, researchers are found in a variety of applied and experimental fields. These fields include clinical psychology, psychophysiology, educational psychology, Industrial and organizational psychology, personality psychology, social psychology, behavioral genetics, and developmental psychology programs, in the neo-Piagetian theories of cognitive development in particular.
Methods of research
To study individual differences, psychologists use a variety of methods. The method is to compare and analyze the psychology and behaviour of individuals or groups under different environmental conditions. By correlating observed psychological and behavioral differences with known accompanying environments, the relative roles of different variables in psychological and behavioral development can be probed. Psychophysiological experiments on both humans and other mammals include EEG and ERPs, PET-scans, MRI, functional MRI, neurochemistry
experiments with neurotransmitter and hormonal systems, caffeine and controlled drug challenges. These methods can be used for a search of biomarkers of consistent, biologically based behavioural patterns (temperament traits and symptoms of psychiatric disorders). Other sets of methods include behavioural experiments, to see how different people behave in similar settings. Behavioural experiments are often used in personality and social psychology, and include lexical and self-report methods where people are asked to complete paper-based and computer-based forms prepared by psychologists.
See also
Educational psychology
Intelligence
Temperament
Personality psychology
Behavioral genetics
References
Introduction to Individual Differences (Wilderdom)
Timeline of researchers and brief biographies
Behavioural sciences
Differential psychology
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History of the present illness
|
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
Questions to include
Different sources include different questions to be asked while conducting an HPI.
Several acronyms have been developed to categorize the appropriate questions to include.
The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of these elements. An "extended HPI" includes four or more of these elements.
Also usable is SOCRATES. For chronic pain, the Stanford Five may be assessed to understand the pain experience from the patient's primary belief system.
See also
Medical record
Medical history
Pain scale
References
External links
Overview at medicine.ucsd.edu
Overview at medinfo.ufl.edu
Medical terminology
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Vitality
|
Vitality (, , ) is the capacity to live, grow, or develop. Vitality is also the characteristic that distinguishes living from non-living things. To experience vitality is regarded as a basic psychological drive and, in philosophy, a component to the will to live. As such, people seek to maximize their vitality or their experience of vitality—that which corresponds to an enhanced physiological capacity and mental state.
Overview
The pursuit and maintenance of health and vitality have been at the forefront of medicine and natural philosophy throughout history. Life depends upon various biological processes known as vital processes. Historically, these vital processes have been viewed as having either mechanistic or non-mechanistic causes. The latter point of view is characteristic of vitalism, the doctrine that the phenomena of life cannot be explained by purely chemical and physical mechanisms.
Prior to the 19th century, theoreticians often held that human lifespan had been less limited in the past, and that aging was due to a loss of, and failure to maintain, vitality.
A commonly held view was that people are born with finite vitality, which diminishes over time until illness and debility set in, and finally death.
Religion
In traditional cultures, the capacity for life is often directly equated with the or . This can be found in the Hindu concept , where vitality in the body derives from a subtle principle in the air and in food, as well as in Hebrew and ancient Greek texts.
Jainism
Vitality and DNA damage
Low vitality or fatigue is a common complaint by older patients. and may reflect an underlying medical illness. Vitality level was measured in 2,487 Copenhagen patients using a standardized, subjective, self-reported vitality scale and was found to be inversely related to DNA damage (as measured in peripheral blood mononuclear cells). DNA damage indicates cellular disfunction.
See also
Urban vitality
Vitalism
References
Jain philosophical concepts
Natural philosophy
Philosophy of life
Quality of life
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Critical infrastructure
|
Critical infrastructure, or critical national infrastructure (CNI) in the UK, describes infrastructure considered essential by governments for the functioning of a society and economy and deserving of special protection for national security. Critical infrastructure has traditionally been viewed as under the scope of government due to its strategic importance, yet there's an observable trend towards its privatization, raising discussions about how the private sector can contribute to these essential services.
Items
Most commonly associated with the term are assets and facilities for:
Shelter; Heating (e.g. natural gas, fuel oil, district heating);
Agriculture, food production and distribution;
Education, skills development and technology transfer / basic subsistence and unemployment rate statistics;
Water supply (drinking water, waste water/sewage, stemming of surface water (e.g. dikes and sluices));
Public health (hospitals, ambulances);
Transportation systems (fuel supply, railway network, airports, harbours, inland shipping);
Security services (police, military).
Electricity generation, transmission and distribution; (e.g. natural gas, fuel oil, coal, nuclear power)
Renewable energy, which are naturally replenished on a human timescale, such as sunlight, wind, rain, tides, waves, and geothermal heat.
Telecommunication; coordination for successful operations
Economic sector; Goods and services and financial services (banking, clearing);
Protection programmes
Canada
The Canadian Federal Government identifies the following 10 Critical Infrastructure Sectors as a way to classify essential assets.
Energy & Utilities: Electricity providers; off-shore/on-shore oil & gas; coal supplies, natural gas providers; home fuel oil; gas station supplies; alternative energy suppliers (wind, solar, other)
Information and Communication Technology: Broadcast Media; telecommunication providers (landlines, cell phones, internet, wifi); Postal services;
Finance: Banking services, government finance/aid departments; taxation
Health: Public health & wellness programs, hospital/clinic facilities; blood & blood products
Food: Food supply chains; food inspectors; import/export programs; grocery stores; Agri & Acqua culture; farmers markets
Water: Water supply & protection; wastewater management; fisheries & ocean protection programs
Transportation: Roads, bridges, railways, aviation/airports; shipping & ports; transit
Safety: Emergency responders; public safety programs
Government: Military; Continuity of governance
Manufacturing: Industry, economic development
European Union
European Programme for Critical Infrastructure Protection (EPCIP) refers to the doctrine or specific programs created as a result of the European Commission's directive EU COM(2006) 786 which designates European critical infrastructure that, in case of fault, incident, or attack, could impact both the country where it is hosted and at least one other European Member State. Member states are obliged to adopt the 2006 directive into their national statutes.
It has proposed a list of European critical infrastructures based upon inputs by its member states.
Each designated European Critical Infrastructures (ECI) will have to have an Operator Security Plan (OSP) covering the identification of important assets, a risk analysis based on major threat scenarios and the vulnerability of each asset, and the identification, selection and prioritisation of counter-measures and procedures.
Germany
The German critical-infrastructure protection programme KRITIS is coordinated by the Federal Ministry of the Interior. Some of its special agencies like the German Federal Office for Information Security or the Federal Office of Civil Protection and Disaster Assistance BBK deliver the respective content, e.g., about IT systems.
Singapore
In Singapore, critical infrastructures are mandated under the Protected Areas and Protected Places Act. In 2017, the Infrastructure Protection Act was passed in Parliament, which provides for the protection of certain areas, places and other premises in Singapore against security risks. It came into force in 2018.
United Kingdom
In the UK, the National Protective Security Authority (NPSA) provides information, personnel and physical security advice to the businesses and organizations which make up the UK's national infrastructure, helping to reduce its vulnerability to terrorism and other threats.
It can call on resources from other government departments and agencies, including MI5, the National Cyber Security Centre (NCSC) and other government departments responsible for national infrastructure sectors.
United States
The U.S. has had a wide-reaching critical infrastructure protection program in place since 1996. Its Patriot Act of 2001 defined critical infrastructure as those "systems and assets, whether physical or virtual, so vital to the United States that the incapacity or destruction of such systems and assets would have a debilitating impact on security, national economic security, national public health or safety, or any combination of those matters."
In 2014 the NIST Cybersecurity Framework was published, and quickly became a popular set of guidelines, despite the significant costs of full compliance.
These have identified a number of critical infrastructures and responsible agencies:
Agriculture and food – Departments of Agriculture and Health and Human Services
Water – Environmental Protection Agency
Public Health – Department of Health and Human Services
Emergency Services – Department of Homeland Security
Government – Department of Homeland Security
Defense Industrial Base – Department of Defense
Information and Telecommunications – Department of Commerce
Energy – Department of Energy
Transportation and Shipping – Department of Transportation
Banking and Finance – Department of the Treasury
Chemical Industry and Hazardous Materials – Department of Homeland Security
Post – Department of Homeland Security
National monuments and icons - Department of the Interior
Critical manufacturing - Department of Homeland Security (14th sector announced March 3, 2008; recorded April 30, 2008)
National Infrastructure Protection Plan
The National Infrastructure Protection Plan (NIPP) defines critical infrastructure sector in the US. Presidential Policy Directive 21 (PPD-21), issued in February 2013 entitled Critical Infrastructure Security and Resilience mandated an update to the NIPP. This revision of the plan established the following 16 critical infrastructure sectors:
Chemical
Commercial facilities
Communications
Critical manufacturing
Dams
Defense industrial base
Emergency services
Energy
Financial services
Food and agriculture
Government facilities
Healthcare and public health
Information technology
Nuclear reactors, materials, and waste
Transportation systems
Water and wastewater systems
National Monuments and Icons along with the postal and shipping sector were removed in 2013 update to the NIPP. The 2013 version of the NIPP has faced criticism for lacking viable risk measures. The plan assigns the following agencies sector-specific coordination responsibilities:
Department of Homeland Security
Chemical
Commercial facilities
Communications
Critical manufacturing
Dams
Emergency services
Government facilities (jointly with General Services Administration)
Information technology
Nuclear reactors, materials, and waste
Transportation systems (jointly with Department of Transportation)
Department of Defense
Defense industrial base
Department of Energy
Energy
Department of the Treasury
Financial services
Department of Agriculture
Food and agriculture
General Services Administration
Government facilities (jointly with Department of Homeland Security)
Department of Health and Human Services
Healthcare and Public Health
Department of Transportation
Transportation systems (jointly with Department of Homeland Security)
Environmental Protection Agency
Water and wastewater systems
State-level legislation
Several U.S. states have passed "critical infrastructure" bills, promoted by the American Legislative Exchange Council (ALEC), to criminalize protests against the fossil fuel industry. In May 2017, Oklahoma passed legislation which created felony penalties for trespassing on land considered critical infrastructure, including oil and gas pipelines, or conspiring to do so; ALEC introduced a version of the bill as a model act and encouraged other states to adopt it. In June 2020, West Virginia passed the Critical Infrastructure Protection Act, which created felony penalties for protests against oil and gas facilities.
Stress testing
Critical infrastructure (CI) such as highways, railways, electric power networks, dams, port facilities, major gas pipelines or oil refineries are exposed to multiple natural and human-induced hazards and stressors, including earthquakes, landslides, floods, tsunami, wildfires, climate change effects or explosions. These stressors and abrupt events can cause failures and losses, and hence, can interrupt essential services for the society and the economy. Therefore, CI owners and operators need to identify and quantify the risks posed by the CIs due to different stressors, in order to define mitigation strategies and improve the resilience of the CIs. Stress tests are advanced and standardised tools for hazard and risk assessment of CIs, that include both low-probability high-consequence (LP-HC) events and so-called extreme or rare events, as well as the systematic application of these new tools to classes of CI.
Stress testing is the process of assessing the ability of a CI to maintain a certain level of functionality under unfavourable conditions, while stress tests consider LP-HC events, which are not always accounted for in the design and risk assessment procedures, commonly adopted by public authorities or industrial stakeholders. A multilevel stress test methodology for CI has been developed in the framework of the European research project STREST, consisting of four phases:
Phase 1: Preassessment, during which the data available on the CI (risk context) and on the phenomena of interest (hazard context) are collected. The goal and objectives, the time frame, the stress test level and the total costs of the stress test are defined.
Phase 2: Assessment, during which the stress test at the component and the system scope is performed, including fragility and risk analysis of the CIs for the stressors defined in Phase 1. The stress test can result in three outcomes: Pass, Partly Pass and Fail, based on the comparison of the quantified risks to acceptable risk exposure levels and a penalty system.
Phase 3: Decision, during which the results of the stress test are analyzed according to the goal and objectives defined in Phase 1. Critical events (events that most likely cause the exceedance of a given level of loss) and risk mitigation strategies are identified.
Phase 4: Report, during which the stress test outcome and risk mitigation guidelines based on the findings established in Phase 3 are formulated and presented to the stakeholders.
This stress-testing methodology has been demonstrated to six CIs in Europe at component and system level: an oil refinery and petrochemical plant in Milazzo, Italy; a conceptual alpine earth-fill dam in Switzerland; the Baku–Tbilisi–Ceyhan pipeline in Turkey; part of the Gasunie national gas storage and distribution network in the Netherlands; the port infrastructure of Thessaloniki, Greece; and an industrial district in the region of Tuscany, Italy. The outcome of the stress testing included the definition of critical components and events and risk mitigation strategies, which are formulated and reported to stakeholders.
See also
Industrial antiterrorism
Infrastructure
Infrastructure security
Civil defense
Paramilitary
References
External links
Infracritical: comparison of US and international definitions of infrastructure
Digital Watch - Critical Infrastructure
United States Department of Homeland Security
Infrastructure
National security
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Polyclinic
|
A polyclinic (where poly means "many"; not to be confused with the homonym policlinic, where poli means "city" and which is sometimes used for a hospital's outpatient department) is a clinic or health care facility that provides both general and specialist examinations and treatments for a wide variety of diseases and injuries to outpatients and is usually independent of a hospital. When a polyclinic is so large that it is in fact a hospital, it is also called a general hospital.
The term was rare in English until recently and is still very rare in North America, examples include the polyclinics in England (large health care centres able to provide a wider range of services than a standard doctor's (GP) office) and The Polyclinic in Seattle, Washington, US.
Most other languages use a cognate of the even rarer English term "policlinic" (spelled similarly to and pronounced the same as the English term "polyclinic") for outpatient departments (outpatient clinics) of (public) hospitals and for large independent (public) clinics for outpatients. Some languages, for example French, specifically use a cognate of "polyclinic" to refer to private outpatient clinics.
Due to the different meanings of "poly" and "poli", it was traditionally considered incorrect to use the English term "polyclinic" for European policlinics. In addition, European policlinics (called "poliklinik", "policlinique", "поликлиника" [poliklinika], or similarly in other languages) are more like hospitals or are part of a hospital and are public and therefore free or inexpensive whereas polyclinics are traditionally much less structured and comprehensive organizations consisting of a usually haphazard collection of more or less independent offices of private doctors. The polyclinics in England however use the term polyclinic more or less like the term policlinic and its cognates in other languages.
See also
References
Clinics
Types of health care facilities
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Holistic nursing
|
Holistic nursing is a way of treating and taking care of the patient as a whole body, which involves physical, social, environmental, psychological, cultural and religious factors. There are many theories that support the importance of nurses approaching the patient holistically and education on this is there to support the goal of holistic nursing. The important skill to be used in holistic nursing would be communicating skills with patients and other practitioners. This emphasizes that patients being treated would be treated not only in their body but also their mind and spirit.. Holistic nursing is a nursing speciality concerning the integration of one's mind, body, and spirit with his or her environment. This speciality has a theoretical basis in a few grand nursing theories, most notably the science of unitary human beings, as published by Martha E. Rogers in An Introduction to the Theoretical Basis of Nursing, and the mid-range theory Empowered Holistic Nursing Education, as published by Dr. Katie Love. Holistic nursing has gained recognition by the American Nurses Association (ANA) as a nursing specialty with a defined scope of practice and standards. Holistic nursing focuses on the mind, body, and spirit working together as a whole and how spiritual awareness in nursing can help heal illness. Holistic medicine focuses on maintaining optimum well-being and preventing rather than just treating disease.
Core values
The holistic philosophy: theory and ethics
Holistic nursing is based on the fundamental theories of nursing, such as the works of Florence Nightingale and Jean Watson as well as alternative theories of world connectedness, wholeness, and healing. Hohistic nurses respect the patient as the decision-maker throughout the continuum of care. The holistic nurse and patient relationship is based on a partnership in which the holistic nurse engages the patient in treatment options and healthcare choices. The holistic nurse seeks to establish a professional and ethical relationship with the patient in order to preserve the patient's sense of dignity, wholesomeness, and inner worth.
Theories of holistic nursing
The goal for holistic nursing is in the definition of holistic where it is to treat the patient in whole not just physically. Various nursing theories have helped on viewing the importance holistic nursing. These theories may differ on the views of holistic nursing care but have common goal which is to treat the patient in whole body and mind. One of the theories is The Intersystem Model, explaining that individuals are holistic being therefore their illness are interacted and adapted them as a whole not just physically. Also as health can be a different value to individuals which ranges constantly from well-being to disease. For example, despite their chronic condition the patient is satisfied with the changed healthy life for their living. In holistic nursing knowing the theory does not mean that this will be implanted in doing in real life practice many nurses are not able to apply the theory in real life.
Holistic caring process
Holistic nursing combines standard nursing interventions with various modalities that are focused on treating the patient in totality. Alternative therapies can include stress management, aroma therapy, and therapeutic touch. The combination of interventions allows the patient to heal in mind, body, and spirit by focusing on the patient's emotions, spirituality, and cultural identity as much as the illness. The six steps of the holistic caring process occur simultaneously, including assessment, diagnosis, outcomes, therapeutic plan of care, implementation, and evaluation. The holistic assessment of the patient can include spiritual, transpersonal, and energy-field assessments in combination with the standard physical and emotional assessments. The therapeutic plan of care in holistic nursing includes a highly individualized and unique plan for each patient. Holistic nurses recognize that the plan of care will change based on the individual patient, and therefore embrace healing as a process that is always changing and adapting to the individual's personal healing journey. Therapies utilized by holistic nurses include stress management techniques and alternative or complementary practices such as reiki and guided imagery. These therapy modalities are focused on empowering individuals to reduce stress levels and elicit a relaxation response in order to promote healing and well-being.
The caring for patients in holistic nursing may differ from other nursing care as some may lack in caring for the patient as a whole, which includes spiritually. In holistic nursing, taking care of the patient does not differ from other nursing, but is focused on mental and spiritual needs as well as physical health. In holistic nursing there should be a therapeutic trust between the patient and nurse, as caring holistically involves knowing the patient's illness as whole. This can be only done by the patient who is the one to tell the nurse about the social, spiritual and internal illness that they are experiencing. Also as caring could be involved as assertive action, quiet support or even both which assist in understanding a person's cultural differences, physical and social needs. Through this the nurse is able to give more holistic care to meet the social and spiritual needs of the patient. The attitude of nurse includes helping, sharing and nurturing. In holistic caring there is spiritual care where it needs an understanding of patient's beliefs and religious views. This is the reason why there should be therapeutic trust between nurse and patient, as in order to understand and respect the patient's religious beliefs the nurse has to get information from the patient directly which is hard to get when there is not therapeutic trust. There is no specific order or template for how to care holistically, but the principle of holistic caring is to include patient's social and internal needs and not just focus on treating the physical illness.
Holistic communication
Holistic nurses use intentional listening techniques ("Focus completely on the speaker") and unconditional positive regard to communicate with patients. The goal of using these communication techniques is to create authentic, compassionate, and therapeutic relationships with each patient.
In holistic nursing having therapeutic trust with patient and nurse gives great advantage of achieving the goal of treating patients as a whole. Therapeutic trust can be developed by having conversation with the patient. In communication the sender can also become a receiver or vice versa which in holistic nursing the nurses are the receiver of patients concern and the pass the information on to the doctor and do the vice versa. As communication is vital element in nursing it is strongly recommended to nurses to understand what is needed and how to communicate with patients. Communicating with patients can help in the performances of nurses in holistic nursing as by communicating the nurses are able to understand the cultural, social values and psychological conditions. Through this the nurses are able to satisfy the needs of a patient and as well as protecting the nurse for doing their roles as a nurse. In holistic nursing non-verbal communication is also another skill that is taught to nurses which are expressed by gestures, facial expression, posture and creating physical barriers. In holistic nursing as all individuals are not all the same but their social and psychological illness should be treated it is up to the nurse on how they communicate in order to build a therapeutic trust. To achieve the goal of holistic nursing it is important to communicate with the patient properly and to this successfully between the nurse and patient is freakiness and honesty. Without these communicating skills the nurse would not be able to build therapeutic trust and is likely to fail the goal of holistic nursing.
Building a therapeutic environment
Holistic nursing focuses on creating not only a therapeutic relationship with patients but also on creating a therapeutic environment for patients. Several of the therapies included in holistic nursing rely on therapeutic environments to be successful and effective. A therapeutic environment empowers patients to connect with the holistic nurse and with themselves introspectively.
Depending on the environment of where the patient is holistic approach may be different and knowing this will help nurses to achieve better in holistic nursing. For patients with illness, trauma and surgery increasing sleep will benefit in recovery, blood pressure, pain relief and emotional wellbeing. As in hospital there are many disturbances which can effect patients’ quality of sleep and due to this the patients are lacking in aid for healing, recovery and emotional wellbeing. Nurse being able note or take care of patient's sleep will determine how closely they are approaching to holistic nursing. Depending on disease some of the treatment may differ and may need further check-ups or programs for patients. For example, there are higher chances for women to experience cardiovascular disease but there are fewer enrollments for cardiac rehabilitation programs compared to men. This was due to the environment of hospital not being able to support females in completing the CR programs. Some examples are physicians are less likely to refer CR programs to women and patient's thought against safety of the program. In situation like this from the knowledge and education that comes from holistic nursing the nurses will be able to approach the patient as they can relate to what the patient is going through which gives more comfort and safety to patients in doing the programs.
Cultural diversity
Part of any type of nursing includes understanding the patient's comprehension level, ability to cope, social supports, and background or base knowledge. The nurse must use this information to effectively communicate with the patient and the patient's family, to build a trusting relationship, and to comprehensively educate the patient. The ability of a holistic nurse to build a therapeutic relationship with a patient is especially important. Holistic nurses ask themselves how they can culturally care for patients through holistic assessment because holistic nurses engage in ethical practices and the treatment of all aspects of the individual.
Australia has many different cultures as they are many people who were born overseas and migrated to Australia, which we can experience many cultural diversities. Culture can be defined as how people create collective beliefs and shared practices in order to make sense of their lived experiences which how concepts of language, religion and ethnicity are built in the culture. As the meaning of holistic nursing to heal the person as a whole knowing their cultural identities or backgrounds will help to reach the goal (Mariano, 2007). Understanding peoples culture may help to approach treatment correctly to the patient as it provides knowledge to nurses how patient's view of the concept of illness and disease are to their values and identity. As in holistic approach culture, beliefs and values are essential components to achieve the goal. People's actions to promote, maintain and restore health and healing are mainly influenced by their culture which is why knowing other cultures will assist in holistic nursing. By developing knowledge, communication, assessment skills and practices for nurses it guides to provide better experiences to patients who have diverse beliefs, values, and behaviors that respects their social, cultural and linguistic needs. As for most patients and families their decision on having treatment against illness or disease are done from cultural beliefs. This means if the nurses are unable to understand and give information relating to what they believe in the patients will most likely reject the treatment and give hardship on holistic nursing.
Holistic education and research
Holistic registered nurses are responsible for learning the scope of practice established in Holistic Nursing: Scope and Standards of Practice(2007) and for incorporating every core value into daily practice. It is the holistic nurse's responsibility to become familiar with both conventional practices as well as alternative therapies and modalities. Through continuing education and research, the holistic nurse will remain updated on all treatment options for patients. Areas of research completed by holistic nurses includes: measurements of outcomes of holistic therapies, measurements of caring behaviors and spirituality, patient responsiveness to holistic care, and theory development in areas such as intentionality, empowerment, and several other topics.
The goal of holistic nursing is treat the patient's individual's social, cognitive, emotional and physical problems as well as understanding their spiritual and cultural beliefs. Involving holistic nursing in the education will help future nurses to be more familiar in the terms holistic and how to approach the concept. In the education of holistic nursing all other nursing knowledge is included which once again developed through reflective practice. In holistic nursing the nurses are taught on the five core values in caring, critical thinking, holism, nursing role development and accountability. These values help the nurse to be able to focus on the health care on the clients, their families and the allied health practitioners who is also involved in patient care. Education in holistic nursing is continuous education program which will be ongoing even after graduation to improve in reaching the goal. Education on holistic nursing would be beneficial to nurses if this concept is introduced earlier as repetition of educating holistic nursing could also be the revision of it. There is different education on commutating skills and an example would be the non-verbal and verbal communication with patients. This is done to improve when would the right or wrong to use the communication skill and how powerful skills this could be.
Holistic nurse self-care
Through the holistic nurse's integration of self-care, self-awareness, and self-healing practices, the holistic nurse is living the values that are taught to patients in practice. Holistic "nurses cannot facilitate healing unless they are in the process of healing themselves."
In order to provide holistic nursing to patient it is also important for nurses to take care of themselves. There are various ways which the nurses can heal, assess and care for themselves such as self-assessment, meditation, yoga, good nutrition, energy therapies, support and lifelong learning. By nurses being able achieve balance and harmony in their lives it can assist to understand how to take care of patient holistically. In Florida Atlantic University there is a program that focus on all caring aspects and recognize how to take care of others as well as on how to start evaluation on their own mind, body and spirit. Also there is Travis’ Wellness Model which explores the idea of “self-care, wellness results from an ongoing process of self-awareness, exploring options, looking within, receiving from others (education), trying out new options (growth), and constantly re-evaluating the entire process. Self-awareness and education precede personal growth and wellness”. This model of concepts shows being able to understand own status of health can benefit to patients and reach the goal of holistic nursing.
Certification
National certification for holistic nursing is regulated by the American Holistic Nurses Certification Corporation (AHNCC). There are two levels of certification: one for nurses holding a bachelor's degree and one for nurses holding a master's degree. Accreditation through the AHNCC is approved by the American Nurses Credentialing Center (ANCC).
Global initiatives
United States
American Holistic Nurses Association (AHNA): Mission Statement
"The Mission of the American Holistic Nurses Association is to illuminate holism in nursing practice, community, advocacy, research and education."
Canada
Canadian Holistic Nurses Association (CHNA): Mission Statement
"To support the practice of holistic nursing across Canada by: acting as a body of knowledge for its practitioners, by advocating with policy makers and provincial regulatory bodies and by educating Canadians on the benefits of complementary and integrative health care."
Australia
Australian Holistic Nurses Association (AHNA)
"The Mission of the Australian Holistic Nurses Association (AHNA) is to illuminate holism in nursing practice, research, and education; act as a body of knowledge for its practitioners; advocate with policymakers and regulatory bodies; and educate Australians on the benefits of Complementary and Alternative Medicine (CAM) and integrative health care."
See also
Alternative medicine
Alternative Therapies in Health and Medicine
Journal of Holistic Nursing
Nursing
References
Nursing specialties
Alternative medicine
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Pattern-Oriented Software Architecture
|
Pattern-Oriented Software Architecture is a series of software engineering books describing software design patterns.
POSA1
Architectural patterns
Layers
Pipes and filters
Blackboard
Broker
Model–View–Controller
Presentation–Abstraction–Control
Design patterns
Whole–Part
Master–Slave
Proxy
Command Processor
View Handler
Forwarder-Receiver
Client–Dispatcher–Server
Publisher–subscriber
POSA2
Service access and configuration patterns
Wrapper Facade
Component Configurator
Interceptor
Extension interface
Event handling patterns
Reactor
Proactor
Asynchronous Completion Token
Acceptor-Connector
Synchronization patterns
Scoped Locking
Strategized Locking
Thread-Safe Interface
Double-checked locking
Concurrency patterns
Active object
Monitor Object
Half-Sync/Half-Async
Leader/Followers
Thread-Specific Storage
POSA3
Resource acquisition
Lookup
Lazy acquisition
Eager acquisition
Resource lifecycle
Caching
Pooling
Coordinator
Resource Lifecycle Manager
Resource release
Leasing
Evictor
POSA4
Software architecture
Domain model
Layers
Model–View–Controller
Presentation–Abstraction–Control
Microkernel
Reflection
Pipes and filters
Shared repository
Blackboard
Domain object
Distribution Infrastructure
Message Channel
Message endpoint
Message translator
Message route
Publisher–subscriber
Broker
Client proxy
Requestor
Invoker
Client request handler
server request handler
Adaptation and execution
Bridge
Object Adapter
Chain of responsitiblity
Interpreter
Interceptor
Visitor
Decorator
Execute-Around Object
Template method
Strategy
Null Object
Wrapper Facade
Declarative component configuration
Resource management
Container
Component Configurator
Object manager
Lookup
Virtual Proxy
Lifecycle callback
Task coordinator
Resource pool
Resource cache
Lazy Acquisition
Eager Acquisition
Partial Acquisition
Activator
Evictor
Leasing
Automated Garbage Collection
Counting Handle
Abstract Factory
Builder
Factory method
Disposal Method
Database access
Database Access Layer
Data mapper
Row Data Gateway
Table Data Gateway
Active Record
POSA5
Patterns referenced in volume 5:
Abstract Factory
Acceptor-Connector
Active Object
Adapted Iterator
Adapter
Align Architecture and Organization (see Conway's Law)
Application Controller
Architect Also Implements
Architecture Follows Organization
Asynchronous Completion Token (ACT)
Automated Garbage Collection
Batch Iterator
Batch Method
Blackboard
Bridge
Broker
Build Prototypes
Builder
Bureaucracy
Business Delegate
Cantrip
Chain of Responsibility
Class Adapter
CLI Server
Client Proxy
Collections for States
Combined Method
Command
Command Processor
Command Sequence (see Composite Command)
Community of Trust
Compiler
Completion Headroom
Component Configurator
Composite
Composite Command
Composite-Strategy-Observer (see Model-View-Controller (MVC))
Context Object
Conway's Law
Cooperate, Don’t Control
CORBA-CGI Gateway
Data Access Object (DAO)
Data is the Next Intel Inside
Data Transfer Object (DTO)
Decorator
Disposal Method
Distributed Callback
Domain Appropriate Devices
Domain Model
Domain Object
Domain Store
Don't Flip the Bozo Bit
Dynamic Invocation Interface (DII)
ed
Encapsulated Context (see Context Object)
Engage Customers
Enumeration Method
Explicit Interface
External Iterator
Facade
Factory Method
Few Panes Per Window
Filter
Firewall Proxy
Flat and Narrow Tree
Forwarder-Receiver
Front Controller
Half-Sync/Half-Asynchronous
Harnessing Collective Intelligence
Immutable Value
Information Just In Time
Interceptor
Internal Iterator (see Enumeration Method)
Interpreter
Invisible Hardware
Involve Everyone
Iterator
Layers
Leader/Followers
Leveraging the Long Tail
Macro Command (see Composite Command)
Manager (see Object Manager)
Mediator
Memento
Message
Methods for States
Mock Object
Model-View-Controller (MVC)
Monitor Object
Mutable Companion
Network Effects by Default
Nouns and Verbs
Null Object
Object Adapter
Object Manager
Objects for States
Observer
Organization Follows Architecture
Page Controller
Perpetual Beta
Pipes and Filters
Pluggable Adapter
Pluggable Factory
Polyvalent-Program
Presentation-Abstraction-Control (PAC)
Proactor
Prototype
Prototype-Abstract Factory (see Pluggable Factory)
Proxy
Publisher-Subscriber
Reactor
Reflection
Remote Proxy (see Client Proxy)
Resource Lifecycle Manager (see Object Manager)
Roguelike
Separated Engine and Interface
Short Menus
Singleton
Sink
Smart Pointer
Software Above the Level of a Single Device
Some Rights Reserved
Source
Stable Intermediate Forms
Standard Panes
State (see Objects for States)
Strategized Locking
Strategy
Template Method
Template View
The Long Tail (see Leveraging the Long Tail)
The Perpetual Beta (see Perpetual Beta)
Transfer Object (see Data Transfer Object)
Transform View
Two-Way Adapter
Users Add Value (see Harnessing Collective Intelligence)
View Handler
Visitor
Window Per Task
Wrapped Class Adapter
Wrapper (see Adapter and Decorator)
Wrapper Facade
1996 non-fiction books
2000 non-fiction books
2004 non-fiction books
2007 non-fiction books
Software development books
Software design patterns
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Partial hospitalization
|
Partial Hospitalization, also known as PHP (partial hospitalization program), is a type of program used to treat mental illness, addiction, or other serious psychological issues. In partial hospitalization, the patient continues to reside at home, but commutes to a treatment center up to seven days a week. Partial hospitalization focuses on the overall treatment of the individual and is intended to avert or reduce in-patient hospitalization.
The pioneer of partial hospital programs, Dr. Albert E. Moll, believed that some patients would be unable to be away from their families or from work and that these programs would reduce the cost of long-term care.
Partial hospitalization programs in the United States can be provided in either a hospital setting or by a free-standing community mental health center (CMHC).
Treatment during a typical day may include group therapy, psych-educational groups, skill building, individual therapy, and psychopharmacological assessments and check-ins.
Programs are available for the treatment of alcoholism and substance abuse problems, Alzheimer's disease, anorexia and bulimia, depression, bipolar disorder, anxiety disorders, schizophrenia, and other mental illnesses. Programs geared specifically toward geriatric patients, adult patients, adolescents, or young children also exist. Programs for adolescents and children usually include an academic program, to either take the place of or to work with the child's local school.
Funding
Service providers in the United States are funded by private insurance as part of a designated continuum of care as well as Medicare and, for some states, Medicaid.
Currently, many providers are moving the partial hospitalization model of day treatment toward more acute short-term services. Hospitals and community mental health organizations are using PHPs to handle acutely ill persons who are able to better understand their illness, become adjusted to medication regimes, develop important coping skills, and set recovery goals that enable them to function effectively as recovered individuals in the society.
Most programs are required to pass comprehensive reviews from national, state, and insurance bodies. Specific guidelines for assessment, treatment, facility maintenance, performance improvement, and client outcome studies are integral to partial hospitalization programs. The Association for Ambulatory Behavioral Healthcare is the premier national group, publishing the Standards and Guidelines for Partial Hospitalization Programs and Intensive Outpatient Programs (2021).
See also
Deinstitutionalisation
Intensive outpatient program (IOP)
Notes
Deinstitutionalisation
Drug rehabilitation
Living arrangements
Treatment of bipolar disorder
Treatment of mental disorders
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Prognosis of schizophrenia
|
The prognosis of schizophrenia is varied at the individual level. In general it has great human and economics costs. It results in a decreased life expectancy of 12–15 years primarily due to its association with obesity, little exercise, and smoking, while an increased rate of suicide plays a lesser role. These differences in life expectancy increased between the 1970s and 1990s, and between the 1990s and 2000s. This difference has not substantially changed in Finland for example – where there is a health system with open access to care.
Schizophrenia is a major cause of disability. Approximately three quarters of people with schizophrenia have ongoing disability with relapses. Still some people do recover completely and additional numbers function well in society.
Most people with schizophrenia live independently with community support. In people with a first episode of psychosis a good long-term outcome occurs in 42% of cases, an intermediate outcome in 35% of cases, and a poor outcome in 27% of cases. Outcome for schizophrenia appear better in the developing than the developed world. These conclusions however have been questioned.
There is a higher than average suicide rate associated with schizophrenia. This has been cited at 10%, but a more recent analysis of studies and statistics places the estimate at 4.9%, most often occurring in the period following onset or first hospital admission. Several times more attempt suicide. There are a variety of reasons and risk factors.
Course
After long-term follow-up half of people with schizophrenia have a favourable outcome while 16% have a delayed recovery after an early unremitting course. More usually, the course in the first two years predicted the long-term course. Early social intervention was also related to a better outcome. The findings were held as important in moving patients, careers and clinicians away from the prevalent belief of the chronic nature of the condition.
This outcome on average however is worse than for other psychotic and otherwise psychiatric disorders though a moderate number of people with schizophrenia were seen to remit and remain well, some of these without need for maintenance medication.
A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years. A 5-year community study found that 62% showed overall improvement on a composite measure of clinical and functional outcomes.
Comorbidity
Those affected by schizophrenia are also more inclined to develop numerous physiological and psychological conditions. Most notably, they experience higher rates of substance abuse and suicidality; where more than half of people with schizophrenia have reported suicide ideation or attempts, and nearly half experience substance abuse or dependence. Because smoking is the most prevalent form of substance abuse among people with schizophrenia, they are also predisposed to a number of physical conditions associated with a high smoking frequency. The rates of smoking for people with schizophrenia is as high as four times that of the general population, contributing to people with schizophrenia increased risk of excess mortality, heart and lung diseases, and even diabetes.
Aging
The prevalence of schizophrenia in adults age 65 and older ranges from 0.1 to 0.5%. Aging is associated with exacerbation of schizophrenia symptoms. Positive symptoms tend to lessen with age, but negative symptoms and cognitive impairments continue to worsen.
Older adults with schizophrenia are prone to extrapyramidal side effects, anticholinergic toxicity, and sedation due to increased body fat, decreased total body water, and decreased muscle mass. Older adults with late-onset schizophrenia usually take half of the typical dose for older adults with early-onset schizophrenia. Continual drug treatment is common for older adults with schizophrenia and the dose may increase with age.
There seem to be gender differences regarding the impact of aging on schizophrenia. Men with schizophrenia tend to have more severe symptoms in the initial stage of the disorder, but gradually improve as they age. However, women with schizophrenia tend to have milder symptoms initially, and progress to more severe symptoms as they age.
The low likelihood of being married and high possibility of outliving their parents and/or siblings may lead to social isolation as one ages.
International
Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions. One US study found that about a third of people made a full recovery, about a third showed improvement, and a third were unchanged.
A clinical study that took into account concurrent remission of positive and negative symptoms, and adequate social and vocational functioning continuously for two years, found a recovery rate of 14% within the first five years. A five-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes. Rates are not always comparable across studies because an exact definition of what constitutes recovery has not been widely accepted, although standardized criteria have been suggested.
The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people with schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia), despite the fact that antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments. On its face, psychiatric medication itself may be causing the worse Western-society outcomes. Large-scale, randomized, blinded studies of alternatives are warranted.
In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. Multiple international surveys by the World Health Organization over several decades have indicated that the outcome for people diagnosed with schizophrenia in non-Western countries is on average better there than for people in the West. Many clinicians and researchers hypothesize that this difference is due to relative levels of social connectedness and acceptance, although further cross-cultural studies are seeking to clarify the findings.
Several factors are associated with a better prognosis: female gender, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms and good premorbid functioning. Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Evidence is also consistent that negative attitudes towards individuals with schizophrenia can have a significant adverse impact, especially within the individual's family. Family members' critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed high 'expressed emotion' or 'EE' by researchers) have been found to correlate with a higher risk of relapse in schizophrenia across cultures.
Defining recovery
Rates are not always comparable across studies because exact definitions of remission and recovery have not been widely established. A "Remission in Schizophrenia Working Group" has proposed standardized remission criteria involving "improvements in core signs and symptoms to the extent that any remaining symptoms are of such low intensity that they no longer interfere significantly with behavior and are below the threshold typically utilized in justifying an initial diagnosis of schizophrenia".
Standardized recovery criteria have also been proposed by a number of different researchers, with the stated DSM definitions of a "complete return to premorbid levels of functioning" or "complete return to full functioning" seen as inadequate, impossible to measure, incompatible with the variability in how society defines normal psychosocial functioning, and contributing to self-fulfilling pessimism and stigma. Some mental health professionals may have quite different basic perceptions and concepts of recovery than individuals with the diagnosis, including those in the Psychiatric survivors movement.
One notable limitation of nearly all the research criteria is failure to address the person's own evaluations and feelings about their life. Schizophrenia and recovery often involve a continuing loss of self-esteem, alienation from friends and family, interruption of school and career, and social stigma, "experiences that cannot just be reversed or forgotten". An increasingly influential model defines recovery as a process, similar to being "in recovery" from drug and alcohol problems, and emphasizes a personal journey involving factors such as hope, choice, empowerment, social inclusion and achievement.
Treatment
While there is no cure for schizophrenia, there are treatment options that aim to reduce symptoms and teach those affected how to manage their day-to-day lives. In 1952, Chlorpromazine became the first typical antipsychotic medication that would effectively reduce hallucinations and delusions by blocking dopamine receptors. Continuous drug discovery has allowed for atypical antipsychotics. Rather than being limited to only blocking dopamine receptors, atypical antipsychotics also block serotonin receptors, which allows for the elevated levels of serotonin in people with schizophrenia to become balanced. With atypical antipsychotics, tremors are often reported as a common side effect because dopamine is involved in processing movement related neurons. In addition to the antipsychotics, people with schizophrenia are also typically prescribed anti-tremor medications. Aside from pharmacological treatment, cognitive behavior therapy is recommended to restructure undesirable thoughts and behaviors. Shown to be the most effective treatment, cognitive behavior therapy is intended to be supplemental to antipsychotic medication. Utilizing cognitive behavior therapy, patients with schizophrenia may learn to replace negative thoughts and behaviors constructively, distinguish reality from hallucinations or delusions, and develop coping skills; while antipsychotics treat symptoms of psychosis. Additionally, the use of atypical antipsychotics is associated with a longer life in comparison to the absence of antipsychotics.
Predictors
Several factors have been associated with a better overall prognosis: Being female, rapid (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms, and good pre-illness functioning. The strengths and internal resources of the individual concerned, such as determination or psychological resilience, have also been associated with better prognosis.
The attitude and level of support from people in the individual's life can have a significant impact; research framed in terms of the negative aspects of this—the level of critical comments, hostility, and intrusive or controlling attitudes, termed high 'expressed emotion'—has consistently indicated links to relapse. Most research on predictive factors is correlational in nature, however, and a clear cause-and-effect relationship is often difficult to establish.
Violence
Most people with schizophrenia are not aggressive, and are more likely to be victims of violence rather than perpetrators. However, though the risk of violence in schizophrenia is small the association is consistent, and there are minor subgroups where the risk is high. This risk is usually associated with a comorbid disorder such as a substance use disorder - in particular alcohol, or with antisocial personality disorder. Substance abuse is strongly linked, and other risk factors are linked to deficits in cognition and social cognition including facial perception and insight that are in part included in theory of mind impairments. Poor cognitive functioning, decision-making, and facial perception may contribute to making a wrong judgement of a situation that could result in an inappropriate response such as violence. These associated risk factors are also present in antisocial personality disorder which when present as a comorbid disorder greatly increases the risk of violence.
A review in 2012 showed that schizophrenia was responsible for 6 per cent of homicides in Western countries. Another wider review put the homicide figure at between 5 and 20 per cent. There was found to be a greater risk of homicide during first episode psychosis that accounted for 38.5 per cent of homicides. The association between schizophrenia and violence is complex. Homicide is linked with young age, male sex, a history of violence, and a stressful event in the preceding year. Clinical risk factors are severe untreated psychotic symptoms – untreated due to either not taking medication or to the condition being treatment resistant. A comorbid substance use disorder or an antisocial personality disorder increases the risk for homicidal behaviour by 8-fold, in contrast to the 2-fold risk in those without the comorbid disorders. Rates of homicide linked to psychosis are similar to those linked to substance misuse, and parallel the overall rate in a region. What role schizophrenia has on violence independent of substance misuse is controversial, but certain aspects of individual histories or mental states may be factors.
Hostility is anger felt and directed at a person or group and has related dimensions of impulsiveness and aggression. When this impulsive-aggression is evident in schizophrenia neuroimaging has suggested the malfunctioning of a neural circuit that modulates hostile thoughts and behaviours that are linked with negative emotions in social interactions. This circuit includes the amygdala, striatum, prefrontal cortex, anterior cingulate cortex, insula, and hippocampus. Hostility has been reported during acute psychosis, and following hospital discharge. There is a known association between low cholesterol levels, and impulsivity, and violence. A review finds that people with schizophrenia, and lower cholesterol levels are four times more likely to instigate violent acts. This association is also linked to the increased number of suicides in schizophrenia. It is suggested that cholesterol levels could serve as a biomarker for violent and suicidal tendencies.
A review found that just under 10 percent of those with schizophrenia showed violent behavior compared to 1.6 percent of the general population. An excessive risk of violence is associated with drugs or alcohol and increases the risk by as much as 4-fold. Violence often leads to imprisonment. Clozapine is an effective medication that can be used in penal settings such as prisons. Cognitive deficits are recognised as playing an important part in the origin and maintenance of aggression, and cognitive remediation therapy may therefore help to prevent the risk of violence in schizophrenia.
References
Schizophrenia
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Syndemic
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Syndemics is the evaluation of how social and health conditions arise, in what ways they interact, and what upstream drivers may produce their interactions. The word is a blend of "synergy" and "epidemics". The idea of syndemics is that no disease exists in isolation and that often population health can be understood through a confluence of factors (such as climate change or social inequality) that produces multiple health conditions that afflict some populations and not others. Syndemics are not like pandemics (where the same social forces produce clustered conditions equally around the world); instead, syndemics reflect population-level trends within certain states, regions, cities, or towns.
A syndemic or synergistic epidemic is generally understood to be the aggregation of two or more concurrent or sequential epidemics or disease clusters in a population with biological interactions, which exacerbate the prognosis and burden of disease. The term was developed by Merrill Singer in the early 1990s to call attention to the synergistic nature of the health and social problems facing the poor and underserved. Syndemics develop under health disparity, caused by poverty, stress, climate, or structural violence and are studied by epidemiologists and medical anthropologists concerned with public health, community health and the effects of social conditions on health. The concept was translated from anthropology to a larger audience in 2017, with the publication of a Series on Syndemics in The Lancet, led by Emily Mendenhall.
The syndemic approach departs from the biomedical approach to diseases to diagnostically isolate, study, and treat diseases as distinct entities separate from other diseases and independent of social contexts.
Definition
A syndemic is a synergistic epidemic. The term was developed by Merrill Singer in the mid-1990s, culminating in a 2009 textbook. Disease concentration, disease interaction, and their underlying social forces are the core concepts.
Disease co-occurrence, with or without interactions, is known as comorbidity and coinfection. The difference between "comorbid" and "syndemic" is per Mustanski et al. "comorbidity research tends to focus on the nosological issues of boundaries and overlap of diagnoses, while syndemic research focuses on communities experiencing co-occurring epidemics that additively increase negative health consequences." It is possible for two afflictions to be comorbid, but not syndemic i.e., the disorders are not epidemic in the studied population, or their co-occurrence does not cause an interaction that then contributes to worsened health. Two or more diseases can be comorbid without interactions, or interaction occurs but it is beneficial, not deleterious. Syndemic theory seeks to draw attention to and provide a framework for the analysis of adverse disease interactions, including their causes and consequences for human life and well-being. Although the majority of this research has focused on HIV, an emerging body of work on syndemics has expanded to other co-occurring conditions.
Syndemic methods: from historical archives to mathematical models
Methods for evaluating syndemics have been a focus on scholarship for deepening the application of what has largely served as theory to understand why and how social and health conditions cluster together, interact, and are driven by shared forces, from climate (such as escalation of heat, rain, drought, and events) to poverty (such as food insecurity, poor housing, lack of safety, and limited work opportunities). In 2022, Alexander Tsai (an epidemiologist), Emily Mendenhall (a medical anthropologist), and Timothy Newfield (a historian) teamed up on a Special Issue in Social Science and Medicine to explore the various methodological ways in which syndemics can be understood, interpreted, and evaluated through history. For instance, historical syndemics may be evaluated using archival data that is incomplete but provides a novel way of thinking about disease biography. This is exemplified by Dylann Atcher Proctor's historical work on gastrointestinal distress in Gabon using historical archives that had never yet been evaluated on their own or synergistically.
Ethnographic data provides a deeper understanding of how and why larger social forces produce disease clusters and interactions and are crucial for understanding "why" syndemics occurr. Ethnographic insights have served as the bedrock of syndemic thinking since Merrill Singer's pioneering intellectual and practical work with the concept beginning in the 1990s. His first article based on ethnographic thinking about the SAVA Syndemic came from real time observations as the AIDS epidemic that unfolded in tandem with substance use amidst structural violence in urban America throughout the 1990s and early 2000s. Singer demonstrated how it was impossible to think about one condition without contextualizing the broader social, structural, and health contexts in which people lived. Discussion of ethnographic methods were detailed in Emily Mendenhall's books Syndemic Suffering and Rethinking Diabetes and is also exemplified in Mac Marshall's book Drinking Smoke.
The largest body of methodological scholarship has emerged around the utility of epidemiological data. Epidemiological data provides opportunities to investigate the synergistic ways in which diseases emerge and interact with social and health conditions. This latter method has been the focus of contention, particularly in dialogue between Alexander Tsai and Ronald Stall. Early epidemiological studies, for example, evaluated the ways in which social and health conditions co-occurred. Tsai argued that instead, there is a deeper need to interrogate how conditions syngistically interact to cause more adverse health conditions that the conditions would produce on their own. This has led to a slough of emergent research interrogating mathematical models that can take seriously how health conditions may cluster together and interact to affect the health and well being of populations residing in a specific nation, region, city, or town. A particularly useful model based on the Soweto Syndemics study was published in Nature Human Behavior. In particular, spatial models for thinking through syndemic clusters, such as using GIS, are an emerging area of interest in syndemics research.
Types of disease interaction
Diseases regularly interact and this interaction influences disease course, expression, severity, transmission, and diffusion. Interaction among diseases may be both indirect (changes caused by one disease that facilitate another through an intermediary) and direct (diseases act in direct tandem).
One disease can assist the physical transmission of the microbe causing another disease, for example, genital-tract ulceration caused by syphilis allowing sexual transmission of HIV.
One disease may enhance the virulence of another, as for example, herpes simplex virus co-infection exacerbates HIV infection with progression to AIDS, periodontal bacteria may enhance the virulence of herpesvirus, HIV-infected individuals are more susceptible to tuberculosis; As of 2011, the cause was not fully understood.
Changes in biochemistry or damage to organ systems, as for example diabetes weakening the immune system, promotes the progression of another disease, SARS.
A coinfection may open up multiple syndemic pathways. Lethal synergism between influenza virus and pneumococcus, causes excess mortality from secondary bacterial pneumonia during influenza epidemics. Influenza virus alters the lungs in ways that increase the adherence, invasion and induction of disease by pneumococcus, alters the immune response with weakened ability to clear pneumococcus or, alternately amplifying the inflammatory cascade.
Direct interaction of diseases occurs in the case of genetic recombination among different pathogens, for instance between Avian sarcoma leukosis virus and Marek's disease virus (MDV) in domestic fowl. Both cancer-causing viruses are known to infect the same poultry flock, the same chicken, and, even the same anatomic cell. In coinfected cells, the retroviral DNA of the avian leukosis virus can integrate into the MDV genome, producing altered biological properties compared to those of the parental MDV. The frequency of gene reassortment among human pathogens is less clear than it is the among plant or animal species but of concern as animal diseases adapt to human hosts and as man new diseases comes into contact.
When one disease diminishes or eradicates another it is a counter-syndemic disease interaction.
The linkage also may not be clear, despite apparent syndemic interactions among diseases, as for example in type 2 diabetes mellitus and hepatitis C virus infection.
Iatrogenic
The term iatrogenesis refers to adverse effects on health caused by medical treatment. This is possible if medical treatment or medical research creates conditions that increase the likelihood that two or more diseases come together in a population. For example, if gene splicing unites two pathogenic agents and the resulting novel organism infects a population. One study suggests the possibility of iatriogenic syndemics. During a randomized, double-blind clinical trial testing the efficacy of the prototype HIV vaccine called V520 there appeared to be an increased risk for HIV infection among the vaccinated participants. Notably, participants immune to the common cold virus adenovirus type 5 had a higher risk of HIV infection. The vaccine was created using a replication-defective version of Ad5 as a carrier, or delivery vector, for three synthetically produced HIV genes. On November 6, 2007, Merck & Co. announced that research had been stopped suspecting the higher rate of HIV infection among individuals in the vaccinated was because the vaccine lowered defenses against HIV.
Examples
Various syndemics though not always labeled as such have been described in the literature, including:
HIV/AIDS and food insecurity compromise an unrecognized syndemic axis in many resource-limited settings in sub-Saharan Africa
SAVA syndemic (substance abuse, violence and AIDS,
the VIDDA syndemic (violence, immigration/isolation, depression, diabetes, abuse)
the hookworm, malaria and HIV/AIDS syndemic,
the Chagas disease, rheumatic heart disease and congestive heart failure syndemic,
the possible asthma and infectious disease syndemic,
the malnutrition and depression syndemic,
the TB, HIV and violence syndemic,
the whooping cough, influenza, tuberculosis syndemic,
the HIV incidence, substance use, mental health, childhood sexual abuse, and intimate partner violence syndemics
the HIV and STD syndemic,
the stress and obesity syndemic,
the HIV infection, mental health and substance abuse syndemic.
the built environment, physical inactivity and obesity/diabetes syndemic, which Prince Charles pointed out in January 2006, in a speech at the Enhancing the Healing Environment conference hosted by The Prince's Foundation for the Built Environment and The King's Fund, St James's Palace, London.
HIV infection and opportunistic microbial infections and viral-caused malignancies like Kaposi's sarcoma
periodontitis and herpes virus: bacteria of several different species (e.g., Porphyromonas gingivalis, Dialister pneumosintes, Prevotella intermedia) that adhere to and reproduce on tooth surfaces under the gum line multiply when bodily defenses are weakened by an HSV infection of the periodontium.
HIV being transiently suppressed during an acute measles infection. Several potential mechanisms could be responsible. Measles virus infection causes lymphopenia, a reduction in the number of CD4+ T lymphocytes circulating in the blood. The low point occurs just prior to the onset of the characteristic skin rash. Within a month of this nadir, the number of lymphocytes returns to normal levels. The drop in HIV virus levels may be due to a lack of target CD4+ T cells in which they replicate, or measles virus may stimulate the production of proteins suppressing HIV replication, including the β-chemokines, CD8+ cell noncytotoxic anti-HIV response, and the cytokines IL-10 and IL-16. median plasma levels of RANTES, a chemokine that attracts immune system components like eosinophils, monocytes, and lymphocytes were higher in HIV-infected children with measles than in those without measles (Moss and co-workers).
HIV suppression in tsutsugamuchi disease or scrub typhus, a mite-borne infection in Asia and Australia, but how this occurs is unclear.
COVID-19 is a syndemic of SARS‑CoV‑2 coronavirus infection combined with an epidemic of non-communicable diseases, both inter-acting on a social substrate of poverty and inequality, according to Richard Horton in the Lancet Global Burden of Disease study 2020 (GBD 2020).
19th century Native American
Contact between Native Americans and Europeans during the Columbian Exchange led to lethal syndemics within the Native American population due to diseases introduced which the Native Americans had not encountered before and had not built-up immunity to.
An example of a syndemic from the 19th century can be found on the reservations on which Native Americans were confined with the closing of the U.S. frontier. It is estimated that in 1860 there were well over 10 million bison living on the American Plains. By the early 1880s, the last of the great herds of bison upon which Plains Indian peoples like the Sioux were dependent as a food source were gone. At the same time, after the U.S. military's defeat at the Battle of the Little Bighorn in 1876, there was a concerted effort to beat the Sioux into total submission. Thus, in 1872, Secretary of the Interior Columbus Delano stated: "as they become convinced that they can no longer rely upon the supply of game for their support, they will return to the more reliable source of subsistence [i.e., farming]." As a result, they were forced to give up their struggle for an independent existence on their own lands and take up reservation life at the mercy of government authority. Treaties that were signed with the Sioux in 1868 and 1876 stipulated that they would be provided with government annuities and provisions in payment for sections of their land and with the expectation among federal representatives that the Sioux would become farmers on individually held plots of land. The Sioux found themselves confined on a series of small reservations where they were treated as a conquered people. Moreover, the government reneged on its promises, food was insufficient and of low quality. Black Elk, a noted Sioux folk healer, told his biographer: "There was hunger among my people before I went across the big water [to Europe in 1886], because the Wasichus [whites] did not give us all the food they promised in the Black Hills treaty... But it was worse when I came back [1889]. My people looked pitiful... We could not eat lies and there was nothing we could do." Under extremely stressful conditions, with inadequate diets, and as victims of overt racism on the part of the registration agents appointed to oversee Indian reserves, the Sioux confronted infectious disease from contact with whites. knowledge about the epidemiology of the Sioux from this period is limited, James Mooney, an anthropologist and representative of the Bureau of Indian Affairs sent to investigate a possible Sioux rebellion, described the health situation on the reservation in 1896: "In 1888 their cattle had been diminished by disease. In 1889, their crops were a failure ... Thus followed epidemics of measles, grippe [influenza], and whooping cough Pertussis, in rapid succession and with terrible fatal results..." Similarly, the Handbook of American Indians notes, "The least hopeful conditions in this respect prevail among the Dakota [Sioux] and other tribes of the colder northern regions, where pulmonary tuberculosis and scrofula are very common... Other more common diseases, are various forms of, bronchitis ...pneumonia, pleurisy, and measles in the young. Whooping cough is also met with." Indian children were removed to white boarding schools and diagnosed with a wide range of diseases, including tuberculosis, trachoma, measles, smallpox, whooping cough, influenza, and pneumonia.
The Sioux were victims of a syndemic of interacting infectious diseases including the 1889–1890 flu pandemic, inadequate diet, and stressful and extremely disheartening life conditions, including outright brutalization with events like the massacre at Wounded Knee in 1890 and the murder of their leader Sitting Bull. While the official mortality rate on the reservation was between one and two percent, the death rate was probably closer to 10 percent.
Influenza
There were three influenza pandemics during the 20th century that caused widespread illness, mortality, social disruption, and significant economic losses. These occurred in 1918, 1957, and 1968. In each case, mortality rates were determined primarily by five factors: the number of people who became infected, the virulence of the virus causing the pandemic, the speed of global spread, the underlying features and vulnerabilities of the most affected populations, and the effectiveness and timeliness of the prevention and treatment measures that were implemented.
The 1957 pandemic was caused by the Asian influenza virus (known as the H2N2 strain), a novel influenza variety to which humans had not yet developed immunities. The death toll of the 1957 pandemic is estimated to have been around two million globally, with approximately 70,000 deaths in the United States. A little over a decade later, the comparatively mild Hong Kong influenza pandemic erupted due to the spread of a virus strain (H3N2) that genetically was related to the more deadly form seen in 1957. The pandemic was responsible for about one million deaths around the world, almost 34,000 of which were in the United States. In both of these pandemics, death may not have been due only to the primary viral infection, but also to secondary bacterial infections among influenza patients; in short, they were caused by a viral/bacterial syndemic (but see Chatterjee 2007).
The worst of the 20th-century influenza pandemics was the 1918 pandemic, where between 20 and 40 percent of the world's population became ill and between 40 and 100 million people died. More people died of the so-called Spanish flu (caused by the H1N1 viral strain) pandemic in the single year of 1918 than during all four-years of the Black Death. The pandemic had devastating effects as disease spread along trade and shipping routes and other corridors of human movement until it had circled the globe. In India, the mortality rate reached 50 per 1,000 population. Arriving during the closing phase of World War I, the pandemic impacted mobilized national armies. Half of U.S. soldiers who died in the "Great War," for example, were victims of influenza. It is estimated that almost of a million Americans died during the pandemic. In part, the death toll during the pandemic was caused by viral pneumonia characterized by extensive bleeding in the lungs resulting in suffocation. Many victims died within 48 hours of the appearance of the first symptom. It was not uncommon for people who appeared to be quite healthy in the morning to have died by sunset. Among those who survived the first several days, however, many died of secondary bacterial pneumonia. It has been argued that countless numbers of those who expired quickly from the disease were co-infected with tuberculosis, which would explain the notable plummet in TB cases after 1918.
Climate change
As a result of the floral changes produced by global warming, an escalation is occurring in global rates of allergies and asthma. Allergic diseases constitute the sixth leading cause of chronic illness in the United States, impacting 17 percent of the population. Asthma affects about 8 percent of the U.S. population, with rising tendency, especially in low income, ethnic minority neighborhoods in cities. In 1980 asthma affected only about three percent of the U.S. population according to the U.S. CDC. Asthma among children has been increasing at an even faster pace than among adults, with the percentage of children with asthma going up from 3.6 percent in 1980 to 9 percent in 2005. Among ethnic minority populations, like Puerto Ricans the rate of asthma is 125 percent higher than non-Hispanic white people and 80 percent higher than non-Hispanic black people. The asthma prevalence among American Indians, Alaska Natives and black people is 25 percent higher than in white people.
Air pollution
Increases in asthma rates have occurred despite improvements in air quality produced by the passage and enforcement of clean air legislation, such as the U.S. Clean Air Act of 1963 and the Clean Air Act of 1990. Existing legislation and regulation have not kept pace with changing climatic conditions and their health consequences. Compounding the problem of air quality is the fact that air-borne pollens have been found to attach themselves to diesel particles from truck or other vehicular exhaust floating in the air, resulting in heightened rates of asthma in areas where busy roads bisect densely populated areas, most notably in poorer inner-city areas.
For every elevation of 10 μg/m3 in particulate matter concentration in the air a six percent increase in cardiopulmonary deaths occurs according to research by the American Cancer Society. Exhaust from the burning of diesel fuel is a complex mixture of vapors, gases, and fine particles, including over 40 known pollutants like nitrogen oxide and known or suspected carcinogenic substances such as benzene, arsenic, and formaldehyde. Exposure to diesel exhaust irritates the eyes, nose, throat and lungs, causing coughs, headaches, light-headedness and nausea, while causing people with allergies to be more susceptible allergy triggers like dust or pollen. Many particles in disease fuel are so tiny they are able to penetrate deep into the lungs when inhaled. Importantly, diesel fuel particles appear to have even greater immunologic effects in the presence of environmental allergens than they do alone. "This immunologic evidence may help explain the epidemiologic studies indicating that children living along major trucking thoroughfares are at increased risk for asthmatic and allergic symptoms and are more likely to have respiratory dysfunction." according to Robert Pandya and co-workers.
The damaging effects of diesel fuel pollution go beyond a synergistic role in asthma development. Exposure to a combination of microscopic diesel fuel particles among people with high blood cholesterol (i.e., low-density lipoprotein, LDL or "bad cholesterol") increases the risk for both heart attack and stroke above levels found among those exposed to only one of these health risks. According to André Nel, Chief of Nanomedicine at the David Geffen School of Medicine at UCLA, "When you add one plus one, it normally totals two... But we found that adding diesel particles to cholesterol fats equals three. Their combination creates a dangerous synergy that wreaks cardiovascular havoc far beyond what's caused by the diesel or cholesterol alone." Experimentation revealed that the two mechanisms worked in tandem to stimulate genes that promote cell inflammation, a primary risk for hardening and blockage of blood vessels (atherosclerosis ) and, as narrowed arteries collect cholesterol deposits and trigger blood clots, for heart attacks and strokes as well.
A Note on Mathematical Models
A mathematical model is a simplified representation using mathematical language to describe natural, mechanical or social system dynamics. Epidemiological modelers unite several types of information and analytic capacity, including: 1) mathematical equations and computational algorithms; 2) computer technology; 3) epidemiological knowledge about infectious disease dynamics, including information about specific pathogens and disease vectors; and 4) research data on social conditions and human behavior. Mathematical modelling in epidemiology is now being applied to syndemics.
For example, modelling to quantify the syndemic effects of malaria and HIV in sub-Saharan Africa based on research in Kisumu, Kenya researchers found that 5% of HIV infections (or 8,500 cases of HIV since 1980) in Kisumu are the result of the higher HIV infectiousness of malaria-infected HIV patients. Additionally, their model attributed 10% of adult malaria episodes (or almost one million excess malaria infections since 1980) to the greater susceptibility of HIV infected individuals to malaria. Their model also suggests that HIV has contributed to the wider geographic spread of malaria in Africa, a process previously thought to be the consequence primarily of global warming. Modelling offers an enormously useful tool for anticipating future syndemics, including eco-syndemic, based on information about the spread of various diseases across the planet and the consequent co-infections and disease interactions that will result.
PopMod is a longitudinal population tool developed in 2003 that models distinct and possibly interacting diseases. Unlike other life-table population models, PopMod is designed to not assume the statistical independence of the diseases of interest. The PopMod has several intended purposes, including describing the time evolution of population health for standard demographic purposes (such as estimating healthy life expectancy in a population), and providing a standard measure of effectiveness for health interventions and cost-effectiveness analysis. PopMod is used as one of the standard tools of the World Health Organization's (WHO) CHOICE (Choosing Interventions that are Cost-Effective) program, an initiative designed to provide national health policymakers in the WHO's 14 epidemiological sub-regions around the world with findings on a range of health intervention costs and effects.
Future research
First, there is a need for studies that examine the processes by which syndemics emerge, the specific sets of health and social conditions that foster multiple epidemics in a population and how syndemics function to produce specific kinds of health outcomes in populations. Second, there is a need to better understand processes of interaction between specific diseases with each other and with health-related factors like malnutrition, structural violence, discrimination, stigmatization, and toxic environmental exposure that reflect oppressive social relationships. There is a need to identify all of the ways, directly and indirectly, that diseases can interact and have, as a result, enhanced impact on human health. Third there is a need for the development of an eco-syndemic understanding of the ways in which global warming contributes to the spread of diseases and new disease interactions.
There is a need for a better understanding of how public health systems and communities can best respond to and limit the health consequences of syndemics. Systems are needed to monitor the emergence of syndemics and to allow early medical and public health responses to lessen their impact. Systematic ethno-epidemiological surveillance with populations subject to multiple social stressors must be one component of such a monitoring system.
See also
Endemic
List of epidemics
List of human diseases associated with infectious pathogens
References
Further reading
Books
Marshall, Mac 2013 Drinking Smoke: The Tobacco Syndemic in Oceania. Honolulu, HI: University of Hawaiʻi Press.
Mendenhall, Emily 2012 Syndemic Suffering: Social Distress, Depression, and Diabetes among Mexican Immigrant Women. Left Coast Press, Inc.
Singer, Merrill 2009 Introduction to Syndemics: A Critical Systems Approach to Public and Community Health. San Francisco, CA: Jossey-Bass.
Articles, chapters
Biello, K.B., Colby, D., Closson, E., Mimiaga, M.J., 2014. "The syndemic condition of psychosocial problems and HIV risk among male sex workers in Ho Chi Minh City, Vietnam". AIDS Behav 18, 1264–1271. .
Biello, K.B., Oldenburg, C.E., Safren, S.A., Rosenberger, J.G., Novak, D.S., Mayer, K.H., Mimiaga, M.J., 2016. Multiple syndemic psychosocial factors are associated with reduced engagement in HIV care among a multinational, online sample of HIV-infected MSM in Latin America. AIDS Care 28 Suppl 1, 84–91. https://doi.org/10.1080/09540121.2016.1146205
Blashill AJ, Bedoya CA, Mayer KH, O'Cleirigh C, Pinkston MM, Remmert JE, Mimiaga MJ, Safren SA. Psychosocial Syndemics are Additively Associated with Worse ART Adherence in HIV-Infected Individuals. AIDS Behav. 2015 Jun;19(6):981-6. doi: 10.1007/s10461-014-0925-6. PMID 25331267; PMCID: PMC4405426.
http://www.dynamicchiropractic.ca/mpacms/dc_ca/article.php?id=55088&no_paginate=true&p_friendly=true&no_b=true
Chu, P., Santos, G.-M., Vu, A., Nieves-Rivera, G., Colfax, J., Grinsdale, S., Huang, S., Phillip, S., Scheer, S. and Aragon, T. 2012 Impact of syndemics on people living with HIV in San Francisco. Presented at the XIX International AIDS Conference, Washington, D.C. (MOACO202 Oral Abstract).
Dyer TV, Turpin RE, Stall R, Khan MR, Nelson LE, Brewer R, Friedman MR, Mimiaga MJ, Cook RL, OʼCleirigh C, Mayer KH. Latent Profile Analysis of a Syndemic of Vulnerability Factors on Incident Sexually Transmitted Infection in a Cohort of Black Men Who Have Sex With Men Only and Black Men Who Have Sex With Men and Women in the HIV Prevention Trials Network 061 Study. Sex Transm Dis. 2020 Sep;47(9):571-579. doi: 10.1097/OLQ.0000000000001208. PMID 32496390; PMCID: PMC7442627
Easton, Delia 2004 The Urban Poor: Health Issues. Encyclopedia of Medical Anthropology, Volume 1, pp. 207–13. New York: Kluwer Academic/Plenum Publishers.
Gilbert, Louisa, Primbetova, Sholpan, Nikitin, Danil, Hunt, Timothy, Terlikbayeva, Assel, Momenghalibaf, Azzi, Murodali, Ruziev and El-Bassel, Nabila 2013 Redressing the epidemics of opioid overdose and HIV among people who inject drugs in Central Asia: The need for a syndemic approach. Drug and Alcohol Dependence (in press).
Guadamuz, Thomas, Friedman, Mark, Marshal, Michael, Herrick, Amy, Lim, Sin How, Wei, Chongyi, and Stall, Ron 2013 Health, Sexual Health, and Syndemics: Toward a Better Approach to STI and HIV Preventive Interventions for Men Who Have Sex with Men (MSM) in the United States. In S. Aral, K. Fenton, J. Lipshuz, Eds. The New Public Health and STD/HIV Prevention: Personal, Public and Health Systems Approaches. New York: Springer Sciences and Business Media.
Hein, Casey and Small, Doreen 2007 Combating Diabetes, Obesity, Periodontal Disease and Interrelated Inflammatory Conditions with a Syndemic Approach.
Herring, D Ann 2008 Viral Panic, Vulnerability and the Next Pandemic. In Health, Risk and Adversity, Catherine Panter-Brick and Agustín Fuentes, Eds, pp 78–100. Oxford, U.K.: Berghahn Books, 2008.
Himmelgreen, David and Romero-Daza, Nancy. Environment: Science and Policy for Sustainable Development "The Global Food Crisis, HIV/AIDS, and Home Gardens"\. Environment: Science and Policy for Sustainable Development June–July 2010.
Jain S, Oldenburg CE, Mimiaga MJ, Mayer KH. High Levels of Concomitant Behavioral Health Disorders Among Patients Presenting for HIV Non-occupational Post-exposure Prophylaxis at a Boston Community Health Center Between 1997 and 2013. AIDS Behav. 2016 Jul;20(7):1556-63. doi: 10.1007/s10461-015-1021-2. PMID 25689892; PMCID: PMC4540681
Johnson, C.V., Mimiaga, M.J., White, J.M., Reisner, S.L., Mayer, K.H. Co-occurring psychosocial conditions additively increase risk for unprotected anal sex among MSM at sex parties. Poster presented at the CDC National HIV Prevention Conference, Atlanta, GA, 2011.
Lim, S.H. Herrick, A., Guadamuz, T., Kao, U., Plankey, M., Ostrow, D., Shoptaw, S. and Stall, R. 2010 Childhood sexual abuse, gay-related victimization, HIV infection and syndemic productions among men who have sex with men (MSM): findings from the Multicenter AIDS Cohort Study (MACS). Presented at the XVIII International AIDS Conference, July 18–23. Vienna, Austria.
Littleton, Juditith and Julia Park 2009 Tuberculosis and syndemics: Implications for Pacific health in New Zealand. Social Science & Medicine (11):1674–80. doi: 10.1016/j.socscimed.2009.08.042. Epub 2009 Sep 27. PMID 19788951.
Littleton, Judith, Julie Park, Ann Herring and Tracy Farmer 2008 Multiplying and Dividing Tuberculosis in Canada and Aotearoa New Zealand, Research in Anthropology and Linguistics e3. University of Auckland.
Lyons, Thomas, Johnson, Amy and Garofalo, Robert 2013 "What Could Have Been Different": A Qualitative Study of Syndemic Theory and HIV Prevention Among Young Men Who Have Sex With Men. Journal of HIV/AIDS & Social Services 2013;12(3-4):10.1080/15381501.2013.816211. doi: 10.1080/15381501.2013.816211. PMID 24244112; PMCID: PMC3825850.
Martin, Yolanda 2013 The Syndemics of Removal: Trauma and Substance Abuse. In Outside Justice: Immigration and the Criminalizing Impact of Changing Policy and Practice edited by David Brotherton, Daniel Stageman and Shirley Leyro. New York: Springer, 91–107.
Mavridis, Agapi 2008 Tuberculosis and Syndemics: Implications for Winnipeg, Manitoba. In Multiplying and Dividing Tuberculosis in Canada and Aotearoa New Zealand, Judith Littleton, Julie Park, Ann Herring and Tracy Farmer, Eds. Research in Anthropology and Linguistics e3: 43–53.
MacQueen, Kate 2002 Anthropology and Public Health. Encyclopedia of Public Health. New York: Macmillan Reference.
McKenzie, Kellye, Mbajah, Joy, Seegers, Angela, and Davis, Celeste 2008 The Landscape of HIV/AIDS among African American Women in the United States. NASTAD National Alliance of State and Territorial AIDS Directors. Issue Brief No. 1:1–12.
Mercado, Susan, Kirsten Havemann, Keiko Nakamura, Andrew Kiyu, Mojgan Sami, Roby Alampay, Ira Pedrasa, Divine Salvador, Jeerawat Na Thalang, and Tran Le Thuey 2007 Responding to the Health Vulnerabilities of the Urban Poor in the 'New Urban Settings' of Asia. Presented at Improving Urban Population Health Systems, sponsored by the Center for Sustainable Urban Development, July.
Millstein, Bobby 2001 Introduction to the Syndemics Prevention Network. Atlanta: Centers for Disease Control and Prevention.
Millstein, Bobby 2004 Syndemics. In: Encyclopedia of Evaluation. Sandra Mathison, Ed. pp. 404–05. Thousand Oaks, CA: Sage Publications.
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Mimiaga, M.J. Hughto, J.M.W., Klasko-Foster, L., Jin, H., Mayer, K.H., Safren, S.A., Biello, K.B. Substance use, mental health problems, and physical and sexual violence additively increase HIV risk between male sex workers and their male clients in Northeastern United States. J Acquir Immune Defic Syndr. 2020 Nov 3. doi: 10.1097/QAI.0000000000002563
Nichter, Mark 2003 "Harm Reduction, Harm Reduction, Ecosocial Epidemiology, Ecosocial Epidemiology, and Syndemics".
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Sibley, Candace Danielle 2011 A Multi-Methodological Study of a Possible Syndemic among Female Adult Film Actresses. MSPH Thesis University of South Florida.
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Singer, Merrill 2008 The Perfect Epidemiological Storm: Food Insecurity, HIV/AIDS and Poverty in Southern Africa. Anthropology Newsletter (American Anthropological Association) 49(7): October 12 & 15.
Singer, Merrill 2008 Drug-related Syndemics and the Risk Environment: Assessing Street risk among Hispanics in Hartford. Presented at the 8th Annual National Hispanic Science Network on Drug Abuse. Bethesda, Maryland.
Singer, Merrill 2009 Desperate Measures: A Syndemic Approach to the Anthropology of Health in a Violent City. In Global Health in the Time of Violence, Barbara Rylko-Bauer, Linda Whiteford, and Paul Farmer, Editors. Santa Fe, NM: SAR Press.
Singer, Merrill 2010 Ecosyndemics: Global Warming and the Coming Plagues of the 21st Century. In Plagues: Models and Metaphors in the Human 'Struggle' with Disease, D. Ann Herring and Alan C. Swedlund, Editors, pp. 21–38. London: Berg.
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Specter, Michael 2005 Higher Risk: Crystal Meth, the Internet, and dangerous Choices about AIDS. The New Yorker, May 23, pp. 39–45.
Stall, Ron 2007 "An Update on Syndemic Theory Among Urban Gay Men" . Presented at the American Public Health Association meetings, Washington, DC. Abstract #155854.
Stall, Ron, Friedman, M.S., and Catania, J. 2007 Interacting Epidemics and Gay Men's Health: A theory of Syndemic Production among Urban Gay Men. In Unequal Opportunity: Health Disparities Affecting Gay and Bisexual Men in the United States, Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri (Eds). Oxford: Oxford University Press.
Stall, Ron, Friedman, M.S., Kurz, M. and Buttram, M.. "2012 Syndemic associations of HIV risk among sex-working MSM in Miami and Ft. Lauderdale, USA". Presented at the XIX International AIDS Conference, Washington, D.C. (MOPE328, Poster exhibit).
Stall, Ron and Mills, Thomas 2006 "Health Disparities, Syndemics and Gay Men's Health" . Presented at the Center for Health Intervention and Prevention. University of Connecticut.
Stall, Ron and van Griensven, Frits 2005 New Directions in Research Regarding Prevention for Positive Individuals: Questions Raised by the Seropositive Urban Men's Intervention Trial. AIDS 19 Supplement 1: S123–27.
Stephens, Christianne V. 2008 "She was Weakly for a Long time and the Consumption Set" In Using Parish Records to Explore Disease Patterns and Causes of Death In a First Nations Community. Research in Anthropology and Linguistics (RAL-e) Monograph Series. Ann Herring, Judith Littleton, Julie Park and Tracy Farmer (eds.) No. 3 134–48.
Stephens, Christianne V. 2009 Syndemics, Structural Violence and the Politics of Health: A Critical Biocultural Approach to the Study of Disease and Tuberculosis Mortality in a Parish Population at Walpole Island (1850–1885). In Proceedings of the 39th Annual Algonquian Conference. Vol. 39 581–613. Karl Hele, (ed). London: University of Western Ontario.
External links
Syndemic Prevention Network: Home
Wayback Machine
Epidemics
Influenza pandemics
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MilSim
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MilSim, an abbreviation of military simulation, refers to live-acted simulation of armed conflict scenarios conducted by civilians for entertainment, sporting, or nostalgic purposes. It has been described as both a form of "extreme sport" and as historical reenactment.
Overview
MilSim includes activities that strive to provide an experience of combat, simulate battlefield missions, or replicate military service-style training. The training is simulated because participants engage in mock scenarios and do not actually engage in real conflicts or use real weaponry. There are several forms of MilSim: physical shooting sports (e.g. airsoft, paintball, or laser tag) with an emphasis on realism based on military scenarios and team tactics; historical reenactment of famous battles; stylistic imitations of a specific military era or focus, such as cosplaying; and military-themed e-sports (e.g. video games). Airsoft guns are used commonly in MilSim due to their cosmetic realism, satisfactory external ballistics, compatibility with genuine firearm accessories, and inexpensive ammunition. Alternatively, mock weapons which fire blanks and blank guns may be used to add immersion in events such as MilSim West. Gel ball blasters are also used by MilSim players who live in countries where airsoft guns are either restricted or banned by law.
Events can span between historical or imaginary battles, law enforcement-style CQC engagements, or freestyle urban/jungle warfare-themed light infantry skirmishes. Large events usually have rigid requirements for entry, and can last several days without leaving the playfield. The experience often includes camping, food preparation, transportation, and other military logistics. MilSim differs from the sports of airsoft or paintball - though all rely on tactics and marksmanship, MilSim has a focus on authenticity to real-world military doctrines. There are often fireteams with designated roles, such as simulated combat medics and support gunners.
Loosely originating in Japan in the 1980s, MilSim events are now bolstered by an active Internet scene. An American presenter, MSATO, claims that MilSim is the "fastest-growing extreme sport worldwide." The largest events can attract thousands of attendees, though players must often source their own equipment, such as specific uniforms, radios, and weapons. Attendees are diverse, consisting of hobbyists, military veterans, or enthusiasts as young as 13. In the United Kingdom, airsoft organizers run in conjunction with Live Action Role-Players (LARP) at British Army training facilities, such as Copehill Down and Catterick Garrison. Elsewhere, combat stages are often salvaged from abandoned buildings and private woodland. Many of the larger playfields are leased to ROTC groups or civilian first responders for their own simulation training.
Reenactments
Similar to historical reenactments, MilSim reenactments have a focus on historical accuracy to a specific event. All weaponry, uniforms, and equipment are suggested or required to be period-accurate. Food, terminology, and living arrangements can be inspired by the period; such as World War II, Desert Storm, or the Yugoslav Wars. Sides are usually not glorified, and attendees are encouraged to see battles through the eyes of an ordinary soldier.
Unlike historical reenactments, which are largely scripted, MilSim events involve creating strategies - on a platoon scale and squad scale - to defeat opponents. War historians are occasionally consulted to help stage the field. Regularly, military veterans from several nations will attend or organize events, giving further accuracy to first-aid training, current terminology, clothing, and tactics. When attendees must source their own equipment, costs can sometimes be thousands of dollars. Occasionally, loaner equipment is provided to beginners.
Simulations
MilSim simulations are fictionalized scenarios with a realistic objective; these can include hostage rescue, bomb defusal, or fictionalized skirmishes, and include law enforcement or militia-themed scenarios. These promote a "tactical playstyle" above casual airsoft. Players are often given an extensive briefing, containing storylines, mission tactics, and rules of engagement. Most simulations strive for immersion and tension in players. MilSim simulations are usually smaller, and more frequent, than reenactments.
Uses
Robert Silverman of Vocativ, embedded in a two-day MilSim (inspired by 2003's Tears of the Sun), writes that "the appeal is in ... the realism of an unreal world, plus a deep desire for the camaraderie and teamwork you'd find in a real military unit." He speculates that the "pure adrenaline free from inflicting actual harm ... strikes at something embedded deep within the core of sports."
Places Journal, referring to the presence of veteran and civilian players describe MilSim as a "ladder leading up to the war and a ladder for coming back down". Notably, veterans (rather than, or in addition to, mental health care) "use war games as self-administered PTSD treatment".
Recently, advances in airsoft replica authenticity have led numerous law enforcement and military units to train with airsoft guns in CQB/CQC environments. MilSim events have encouraged the US Army to promote enlistment.
Video games
Mil-sim is also the descriptor for a genre of video games, often overlapping with the tactical shooter genre, containing more "realistic" mechanics and consequences than typical first-person shooters or action games. Games such as Arma and Squad rather than pure entertainment, are a simulation of equipment and tactics, and are sometimes used for military training and mission rehearsal. Other games, such as Red Orchestra: Ostfront 41-45 and Insurgency: Sandstorm, feature realistic aspects in their gameplay. Mil-sims can be differentiated from other shooter games in that, commonly:
Tactics similar to ones used by real life military are effective.
Firearms are modeled after real life. Bullets are grouped by magazines (rather than an ammo pool), gunshot wounds are usually fatal, and bullets are physically simulated, requiring the player to account for wind and gravity.
The games' systems account for various needs. Vehicles may have limited cargo space, and characters can become severely fatigued, including hunger and thirst.
Community-run MilSim events within these video games, often have players undergo "training". A player might be trained in military tactics that will give them an advantage in the game.
See also
Small Arms Weapons Effects Simulator
Renaissance fair
Urban exploration
References
External links
Catalog of Wargaming and Military Simulation Models - Defense Technical Information Center
The ‘TACWAR’ Wargame - Marine Corps Association
Combat sports
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After-action review
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An after action review (AAR) is a technique for improving process and execution by analyzing the intended outcome and actual outcome of an action and identifying practices to sustain, and practices to improve or initiate, and then practicing those changes at the next iteration of the action AARs in the formal sense were originally developed by the U.S. Army. Formal AARs are used by all US military services and by many other non-US organizations. Their use has extended to business as a knowledge management tool.
An AAR occurs within a cycle of establishing the leader's intent, planning, preparation, action and review. An AAR is distinct from a de-brief in that it begins with a clear comparison of intended versus actual results achieved. An AAR is forward-looking, with the goal of informing future planning, preparation, and execution of similar actions. Assigning blame or issuing reprimands is antithetical to the purpose of an AAR. An AAR is distinct from a post-mortem in its tight focus on participants' own actions; learning from the review is taken forward by the participants. Recommendations for others are not produced.
AARs in larger operations can be cascaded in order to keep each level of the organization focused on its own performance within a particular event or project.
Formal AAR meetings are normally run by a facilitator or trained 'AAR Conductor', and can be chronological reviews or tightly focused on a few key issues selected by the team leader. Short cycle informal AARs are typically run by a team leader or assistant and are very quick.
After action reviews in the British National Health Service
In the United Kingdom's National Health Service (NHS), AAR is increasingly used as a learning tool to promote patient safety and improve care, as outlined by Walker et al. 2012. In the UK and Europe other healthcare organisations, including pharmaceutical and medical technology businesses such as BD, are beginning to roll out their own AAR programmes.
In 2008, a group of senior leaders within University College London Hospitals NHS Foundation Trust acted on the realization that bullying and blaming behaviours were impacting on safe and effective care. They commissioned the UCLH Education service to tackle the problem, and AAR was chosen as the tool to use.
In 20011, Professor Aidan Hallighan, UCLH's Director of Education, wrote "Healthcare is dominated by the extreme, the unknown and the very improbable with high impact consequences, conditions that demand leadership, and yet we spend our time focusing on what we know and what we can control. Educating staff on the use of After Action Review enables team working and cues behaviours through allowing an emotional mastery of the moment and learning after doing."
"AARs are applicable to almost any event, clinical or otherwise, and whilst the emphasis is on learning after less than perfect events, AARs after successful experiences can also provide rich benefits. Prerequisite to the success of a formal AAR are a few key ingredients, including a trained ‘conductor’, a suitable safe private environment, allocated time and the assumption of equality of everybody present. Every AAR follows the same structure with the conductor getting agreement for the ground rules at the outset and ensuring everyone is clear about the specific purpose of the AAR and the four apparently simple questions to be used."
AAR is actively used in a number of NHS organisations including Cambridge University Hospitals, Bedfordshire Hospitals and NEL Healthcare Consulting and has been recommended as an approach to be used in the new NHS Patient Safety Incident Response Framework, which "moves away from reactive and hard-to-define thresholds for 'Serious Incident' investigation and towards a proactive approach to learning from incidents."
See also
List of established military terms
After action report
Morbidity and mortality conference
References
External links
Homeland Security Digital Library Leader's Guide to After-Action Reviews (Alternate Title: Army Training Circular 25-20: Leader's Guide to After-Action Reviews).
UNICEF After Action Review, September 2015
Military education and training
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Buddhism and psychology
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Buddhism includes an analysis of human psychology, emotion, cognition, behavior and motivation along with therapeutic practices. Buddhist psychology is embedded within the greater Buddhist ethical and philosophical system, and its psychological terminology is colored by ethical overtones. Buddhist psychology has two therapeutic goals: the healthy and virtuous life of a householder (samacariya, "harmonious living") and the ultimate goal of nirvana, the total cessation of dissatisfaction and suffering (dukkha).
Buddhism and the modern discipline of psychology have multiple parallels and points of overlap. This includes a descriptive phenomenology of mental states, emotions and behaviors as well as theories of perception and unconscious mental factors. Psychotherapists such as Erich Fromm have found in Buddhist enlightenment experiences (e.g. kensho) the potential for transformation, healing and finding existential meaning. Some contemporary mental-health practitioners such as Jon Kabat-Zinn find ancient Buddhist practices (such as the development of mindfulness) of empirically therapeutic value, while Buddhist teachers such as Jack Kornfield see Western psychology as providing complementary practices for Buddhists.
Interaction
The establishment of Buddhism predates the field of psychology by over two millennia; thus, any assessment of Buddhism in terms of psychology is necessarily a modern invention. One of the first such assessments occurred when British Indologists started translating Buddhist texts from Pali and Sanskrit. The modern growth of Buddhism in the West and particularly the development of Buddhist modernism worldwide has led to the comparing and contrasting of European psychology and psychiatry with Buddhist theory and practice. According to Austrian psychologist Gerald Virtbauer, the contact of Buddhism and European Psychology has generally followed three main approaches:
The presentation and exploration of parts of Buddhist teachings as a Psychology and psychological method for analyzing and modifying human experience.
The integration of parts of the Buddhist teachings in already existing psychological or psychotherapeutic lines of thought (such as in mindfulness-based cognitive therapy and in acceptance and commitment therapy).
Buddhist integration of Western psychological and social science knowledge into the Buddhist system (e.g., Buddhist modernism, Vipassana movement)
Psychology in the Tripitaka
The earliest Buddhist writings are preserved in three-part collections called Tipitaka (Pali; Skt. Tripitaka). The first part, the Sutta Pitaka contains a series of discourses attributed to the Buddha containing much psychological material.
A central feature of Buddhist psychology is its methodology which is based on personal experience through introspection and phenomenological self observation. According to the Buddha while initially unreliable, one's mind can be trained, calmed and cultivated so as to make introspection a refined and reliable method. This methodology is the foundation for the personal insight into the nature of the mind the Buddha is said to have achieved. While introspection is a key aspect of the Buddhist method; observation of a person's behavior is also important.
Perception and the self
The early Buddhist texts outline a theory of perception and cognition based on the ayatanas (sense bases, sense media, sense spheres) which are categorized into sense organs, sense objects and awareness. The contact between these bases leads to a perceptual event as explained in Buddhist texts: "when the eye that is internal is intact and external visible forms come within its range and when there is an appropriate act of attention on the part of the mind, there is the emergence of perceptual consciousness."
The usual process of sense cognition is entangled with what the Buddha terms "papañca" (conceptual proliferation), a distortion and elaboration in the cognitive process of the raw sensation or feeling (vedana). This process of confabulation feeds back into the perceptual process itself. Therefore, perception for the Buddhists is not just based on the senses but also on our desires, interests and concepts and hence it is in a way unrealistic and misleading. The goal of Buddhist practice is then to remove these distractions and gain knowledge of things as they are (yatha-bhuta ñānadassanam).
This psycho-physical process is further linked with psychological craving, manas (conceit) and ditthi (dogmas, views). One of the most problematic views according to the Buddha, is the notion of a permanent and solid Self or 'pure ego'. This is because in early Buddhist psychology, there is no fixed self (atta; Sanskrit atman) but the delusion of self and clinging to a self concept affects all one's behaviors and leads to suffering. For the Buddha there is nothing uniform or substantial about a person, only a constantly changing stream of events or processes categorized under five categories called skandhas (heaps, aggregates), which includes the stream of consciousness (Vijñāna-sotam). False belief and attachment to an abiding ego-entity is at the root of most negative emotions.
The psychologist Daniel Goleman states:
The Buddha saw the human mind as a psycho-physical complex, a dynamic continuum called namarupa. Nama refers to the non-physical elements and rupa to the physical components. According to Padmasiri de Silva, "The mental and physical constitutents form one complex, and there is a mutual dependency of the mind on the body and of the body on the mind."
Motivation and emotion
Buddha's theory of human motivation is based on certain key factors shared by all human beings and is primarily concerned with the nature of human dissatisfaction (dukkha) and how to dispel it. In the suttas, human beings are said to be motivated by craving (tanha, literally 'thirst') of three types:
Kama tanha - craving for sensory gratification, sex, novel stimuli, and pleasure.
Bhava tanha - craving for survival or continued existence, also includes hunger and sleep as well as desire for power, wealth and fame.
Vibhava tanha - craving for annihilation, non-existence, also associated with aggression and violence towards oneself and others
These three basic drives have been compared to the Freudian drive theory of libido, ego, and thanatos respectively (de Silva, 1973). The arousal of these three cravings is derived from pleasant or unpleasant feelings (vedana), reactions to sense impressions with positive or negative hedonic tone. Cravings condition clinging or obsession (upadana) to sense impressions, leading to a vicious cycle of further craving and striving, which is ultimately unsatisfactory and stressful.
The suttas also enumerate three "unwholesome roots" (akusala mulas) of suffering, negative emotions and behavior: raga (passion or
lust); dosa (hatred or malice); and moha (delusion, or false belief). These are opposed by three wholesome roots: liberality, kindness and wisdom.
Feeling or affective reaction (vedana) is also at the source of the emotions and it is categorized in various ways; as physical or mental, as pleasant, unpleasant or neutral; and as rooted in the different senses. The Buddha also makes a distinction between worldly and unworldly or spiritual feelings, seeing spiritual feelings as superior. Out of these basic immediate reactions as well as our situational context, conceptualization and personal history arise more complex emotions, such as fear, hatred, hope or despair. The Buddhist theory of emotions also highlights the ethical and spiritual importance of positive emotions such as compassion and friendliness as antidotes for negative emotions and as vehicles for self development.
According to Padmasiri de Silva, in the early Buddhist texts emotions can be divided into four groups: "those which obstruct the ideal of the virtuous life sought by the layman, emotions that interfere with the recluse seeking the path of perfection, emotions enhancing the layman's ideal of the virtuous life and emotions developed by the recluse seeking the path of perfection."
The Unconscious
The early Buddhist texts such as the Pali Canon present a theory about latent mental tendencies (Anusaya, "latent bias", "predisposition", "latent disposition") which are pre-conscious or non-conscious These habitual patterns are later termed "Vāsanā" (impression) by the later Yogacara Buddhists and were held to reside in an unconscious mental layer. The term "fetter" is also associated with the latent tendencies.
A later Theravada text, the Abhidhammattha-sangaha (11th-12th century) says: "The latent dispositions are defilements which 'lie along with' the mental process to which they belong, rising to the surface as obsessions whenever they meet with suitable conditions" (Abhs 7.9). The Theravada school also holds that there is a subconscious stream of awareness termed the Bhavanga.
Another set of unconscious mental factors responsible for influencing one's behavior include the asavas (Sanskrit asrava, "influx, canker, inflows"). These factors are said to "intoxicate" and "befuddle" the mind. The Buddha taught that one had to remove them from the mind through practice in order to reach liberation. The asavas are said to arise from different factors: sensuality, aggression, cruelty, body, and individuality are some of the factors given.
The Yogacara school of Mahayana Buddhism (starting from the 3rd to 5th century CE) extended these ideas into what has been called a Buddhist theory of the Unconscious mind. This concept was termed the ālaya-vijñāna (the foundation consciousness) which stores karmic seeds (bija) and undergoes rebirth. This theory was incorporated into a wider Yogacara theory of the Eight Consciousnesses and is also held in Tibetan Buddhism.
Self development and cognitive behavioral practices
According to Padmal de Silva "Buddhist strategies represent a therapeutic model which treats the person as his/her agent of change, rather than as the recipient of externally imposed interventions." Silva argues that the Buddha saw each person responsible for their own personal development and considers this as being similar to the humanistic approach to psychology. Humanistic psychotherapy places much emphasis on helping the client achieve self-actualization and personal growth (e.g. Maslow).
Since Buddhist practice also encompasses practical wisdom, spiritual virtues and morality, it cannot be seen exclusively as another form of psychotherapy. It is more accurate to see it as a way of life or a way of being (Dharma).
Personal development in Buddhism is based upon the Noble Eightfold Path which integrates ethics, wisdom or understanding (pañña) and psychological practices such as meditation (bhavana, cultivation, development). Self-actualization in traditional Buddhism is based on the ideas of Nirvana and Buddhahood. The highest state a human can achieve (an Arahant or a Buddha) is seen as being completely free from any kind of dissatisfaction or suffering, all negative mental tendencies, roots and influxes have been eliminated and there are only positive emotions like compassion and loving-kindness present.
Buddhist meditation is of two main types: Samatha is meant to calm and relax the mind, as well as develop focus and concentration by training attention on a single object; Vipassana is a means to gain insight or understanding into the nature of the mental processes and their impermanent, stressful and self-less qualities through the application of continuous and stable mindfulness and comprehension (Sampajañña). Though the ultimate goal of these practices are nirvana, the Buddha stated that they also bring mundane benefits such as relaxation, good sleep and pain reduction.
Buddhist texts also contain mental strategies of thought modification which are similar to cognitive behavioral therapy techniques. A comparison of these systems of cognitive behavioral modification has been discussed by professor William Mikulas and Padmal de Silva.
According to Padmal de Silva these similarities include: "fear reduction by graded exposure and reciprocal inhibition; using rewards for promoting desirable behavior; modelling for inducing behavioral change; the use of stimulus control to eliminate undesirable behavior; the use of aversion to eliminate undesirable behavior; training in social skills; self-monitoring; control of intrusive thoughts by distraction, switching/stopping, incompatible thoughts, and by prolonged exposure to them; intense, covert, focusing on the unpleasant aspects of a stimulus or the unpleasant consequences of a response, to reduce attachment to the former and eliminate the latter; graded approach to the development of positive feelings towards others: use of external cues in behavior control; use of response cost to aid elimination of undesirable behavior; use of family members for carrying out behavior change programs; and cognitive-behavioral methods—for example, for grief."
An important early text for these cognitive therapeutic methods is the Vitakkasanthana Sutta (MN 20) (The Removal of Distracting Thoughts) and its commentary, the Papancasudani. For removing negative or intrusive thoughts, the Buddha recommended five methods in this sutta:
Focus on an opposite or incompatible thought or object.
Ponder on the perils and disadvantages of the thought, its harmful consequences.
Ignore the thought and distract yourself from it through some other activity.
Reflect on the removal or stopping of the causes of the target thought.
Make a forceful mental effort.
Another recommended technique is from the Satipatthana Sutta, which outlines the practice of mindfulness, which is not just a formal meditation, but a skill of attentive awareness and self monitoring. In developing mindfulness, one is advised to be aware of all thoughts and sensations that arise, even unwanted or unpleasant ones and continuously attend to such thoughts. Eventually, through habituation and exposure, the intensity and unpleasantness of such thoughts will disappear. Buddhist texts also promote the training of positive emotions such as loving-kindness, compassion, empathetic joy and equanimity.
Abnormal psychology
The Pali Canon records that the Buddha distinguished between two kinds of illness (rogo): physical illness (kāyiko rogo) and mental illness (cetasiko rogo). The Buddha attributed mental illness to the arising of mental defilements (Kleshas) which are ultimately based on the unwholesome roots (three poisons) of greed, hatred and confusion. From the perspective of the Buddha, mental illness is a matter of degree, and ultimately, everyone who is not an awakened being is in some sense mentally ill. As the Buddha in the Pali canon states: "those beings are hard to find in the world who can admit freedom from mental disease even for one moment, save only those in whom the asavas are destroyed." Another set of negative qualities outlined by the Buddha are the five hindrances, which are said to prevent proper mental cultivation, these are: sense desire, hostility, sloth-torpor, restlessness-worry and doubt.
According to Edwina Pio, Buddhist texts see mental illness as being mainly psychogenic in nature (rooted mainly in "environmental stress and inappropriate learning").
The Pali canon also describes Buddhist monks (epitomized by the monk Gagga) with symptoms of what would today be called mental illness. An act which is against the monk's code of discipline (Vinaya) committed by someone who was "ummatta" - "out of his mind" was said by the Buddha to be pardonable. This was termed the madmans leave (ummattakasammuti) The texts also assume that this 'madness' can be cured or recovered from, or is at least an impermanent phenomenon, after which, during confession, the monk is considered sane by the sangha once more.
There are also stories of lay folk who show abnormal behavior due to the loss of their loved ones. Other Buddhist sources such as the Milinda Panha echo the theory that madness is caused mainly by personal and environmental circumstances.
Other abnormal behaviors described by the early sources include Intellectual disability, epilepsy, alcoholism, and suicide. Buddhagosa posits that the cause of suicide is mental illness based on factors such as loss of personal relations and physical illness.
Abhidhamma psychology
The third part (or pitaka, literally "basket") of the Tripitaka is known as the Abhidhamma (Pali; Skt. Abhidharma). The Abhidhamma works are historically later than the two other collections of the Tipitaka (3rd century BCE and later) and focus on phenomenological psychology. The Buddhist Abhidhamma works analyze the mind into elementary factors of experience called dharmas (Pali: dhammas). Dhammas are phenomenal factors or "psycho-physical events" whose interrelations and connections make up all streams of human experience. There are four categories of dharmas in the Theravada Abhidhamma: Citta (awareness), Cetasika (mental factors), Rūpa (physical occurrences, material form) and Nibbāna (cessation). Abhidhamma texts are then an attempt to list all possible factors of experience and all possible relationships between them. Among the achievements of the Abhidhamma psychologists was the outlining of a theory of emotions, a theory of personality types, and a psychology of ethical behavior.
Ven. Bhikkhu Bodhi, president of the Buddhist Publication Society, has synopsized the Abhidhamma as follows:
Buddhism and psychology
Buddhism and psychology overlap in theory and in practice. Since the beginning of the 20th century, four strands of interplay have evolved:
descriptive phenomenology: scholars have found in Buddhist teachings a detailed introspective phenomenological psychology (particularly in the Abhidhamma which outlines various traits, emotions and personality types).
psychotherapeutic meaning: humanistic psychotherapists have found in Buddhism's non-dualistic approach and enlightenment experiences (such as in Zen kensho) the potential for transformation, healing and finding existential meaning. This connection was explained by a modification of Piaget's theory of cognitive development introducing the process of initiation.
clinical utility: some contemporary mental-health practitioners increasingly find ancient Buddhist practices (such as the development of mindfulness) of empirically proven therapeutic value.
popular psychology and spirituality: psychology has been popularized, and has become blended with spirituality in some forms of modern spirituality. Buddhist notions form an important ingredient of this modern mix.
Psychology
The contact between Buddhism and Psychology began with the work of the Pali Text Society scholars, whose main work was translating the Buddhist Pali Canon. In 1900, Indologist Caroline A. F. Rhys Davids published through the Pali Text Society a translation of the Theravada Abhidhamma's first book, the Dhamma Sangani, and entitled the translation, "Buddhist Manual of Psychological Ethics". In the introduction to this seminal work, Rhys Davids praised the sophistication of the Buddhist psychological system based on "a complex continuum of subjective phenomena" (dhammas) and the relationships and laws of causation that bound them (Rhys Davids, 1900, pp. xvi-xvii.). Buddhism's psychological orientation is a theme Rhys Davids pursued for decades as evidenced by her further publications, Buddhist Psychology: An Inquiry into the Analysis and Theory of Mind in Pali Literature (1914) and The Birth of Indian Psychology and its Development in Buddhism (1936).
An important event in the interchange of East and West occurred when American psychologist William James invited the Sri Lankan Buddhist Anagarika Dharmapala to lecture in his classes at Harvard University in December 1903. After Dharmapala lectured on Buddhism, James remarked, "This is the psychology everybody will be studying 25 years from now." Later scholars such as David Kalupahana (The principles of Buddhist psychology, 1987), Padmal de Silva (Buddhism and behaviour modification, 1984), Edwina Pio and Hubert Benoit (Zen and the Psychology of Transformation, 1990) wrote about and compared Buddhism and Psychology directly. Writers in the field of transpersonal psychology (which deals with religious experience, altered states of consciousness and similar topics) such as Ken Wilber also integrated Buddhist thought and practice into their work.
The 1960s and 1970s saw the rapid growth of Western Buddhism, especially in the United States. In the 1970s, psychotherapeutic techniques using "mindfulness" were developed such as Hakomi therapy by Ron Kurtz (1934–2011), possibly the first mindfulness based therapy. Jon Kabat-Zinn's mindfulness-based stress reduction (MBSR) was a very influential development, introducing the term into Western cognitive behavioral therapy practice. Kabat-Zinn's students Zindel V. Segal, J. Mark G. Williams and John D. Teasdale later developed mindfulness-based cognitive therapy (MBCT) in 1987. In the early 2000s Vidyamala Burch and her organization Breathworks developed mindfulness-based pain management (MBPM).
More recent work has focused on clinical research of particular practices derived from Buddhism such as mindfulness meditation and compassion development (ex. the work of Jon Kabat-Zinn, Daniel Goleman) and on psycho-therapeutic practices which integrate meditative practices derived from Buddhism. From the perspective of Buddhism, various modern Buddhist teachers such as Jack Kornfield and Tara Brach have academic degrees in psychology.
Applying the tools of modern neuropsychology (EEG, fMRI) to study Buddhist meditation is also an area of integration. One of the first figures in this area was neurologist James H. Austin, who wrote Zen and the Brain (1998). Others who have studied and written about this type of research include Richard Davidson, B. Alan Wallace, Rick Hanson (Buddha's Brain, 2009) and Zoran Josipovic. A recent review of the literature on the Neural mechanisms of mindfulness meditation concludes that the practice "exerts beneficial effects on physical and mental health, and cognitive performance" but that "the underlying neural mechanisms remain unclear."
Japanese psychology
In Japan, a different strand of comparative thought developed, beginning with the publication, "Psychology of Zen Sect" (1893) and "Buddhist psychology" (1897), by Inoue Enryō (1858–1919). In 1920, Tomosada Iritani (1887–1957) administered a questionnaire to 43 persons dealing with Zen practice, in what was probably the first empirical psychological study of Zen. In the field of psychotherapy, Morita therapy was developed by Shoma Morita (1874-1938) who was influenced by Zen Buddhism.
Koji Sato (1905–1971) began the publication of the journal, Psychologia: An International Journal of Psychology in the Orient in 1957 with the aim of providing a comparative psychological dialogue between East and West (with contributions from Bruner, Fromm, and Jung). In the 1960s, Kasamatsu and Hirai used Electroencephalography to monitor the brains of Zen meditators. This led to the promotion of various studies covering psychiatry, physiology, and psychology of Zen by the Japanese ministry of education which were carried out in various laboratories. Another important researcher in this field, Prof. Yoshiharu Akishige, promoted Zen Psychology, the idea that the insights of Zen should not just be studied but that they should inform psychological practice. Research in this field continues with the work of Japanese psychologists such as Akira Onda and Osamu Ando.
In Japan, a popular psychotherapy based on Buddhism is Naikan therapy, developed from Jōdo Shinshū Buddhist introspection by Ishin Yoshimoto (1916–1988). Naikan therapy is used in correctional institutions, education, to treat alcohol dependence as well as by individuals seeking self development.
Buddhism and psychoanalysis
Buddhism has some views which are comparable to psychoanalytic theory. These include a view of the unconscious mind and unconscious thought processes, the view that unwholesome unconscious forces cause much of human suffering and the idea that one may gain insight into these thought processes through various practices, including what Freud called "evenly suspended attention." A variety of teachers, clinicians and writers such as D.T. Suzuki, Carl Jung, Erich Fromm, Alan Watts, Tara Brach, Jack Kornfield and Sharon Salzberg have attempted to bridge and integrate psycho-analysis and Buddhism. British barrister Christmas Humphreys has referred to mid-twentieth century collaborations between psychoanalysts and Buddhist scholars as a meeting between: "Two of the most powerful forces operating in the Western mind today."
D.T. Suzuki's influence
One of the most important influences on the spread of Buddhism in the west was Zen scholar D.T. Suzuki. He collaborated with psycho-analysts Carl Jung, Karen Horney and Erich Fromm.
Carl Jung wrote the foreword to Suzuki's Introduction to Zen Buddhism, first published together in 1948. In his foreword, Jung highlights the enlightenment experience of satori as the "unsurpassed transformation to wholeness" for Zen practitioners. And while acknowledging the inadequacy of Psychologist attempts to comprehend satori through the lens of intellectualism, Jung nonetheless contends that due to their shared goal of self transformation: "The only movement within our culture which partly has, and partly should have, some understanding of these aspirations [for such enlightenment] is psychotherapy."
Referencing Jung and Suzuki's collaboration as well as the efforts of others, humanistic philosopher and psychoanalyst Erich Fromm noted that: "There is an unmistakable and increasing interest in Zen Buddhism among psychoanalysts". One influential psychoanalyst who explored Zen was Karen Horney, who traveled to Japan in 1952 to meet with Suzuki and who advised her colleagues to listen to their clients with a "Zen-like concentration and non attachment".
Suzuki, Fromm and other psychoanalysts collaborated at a 1957 workshop on "Zen Buddhism and Psychoanalysis" in Cuernavaca, Mexico. Fromm contends that, at the turn of the twentieth century, most psychotherapeutic patients sought treatment due to medical-like symptoms that hindered their social functioning. However, by mid-century, the majority of psychoanalytic patients lacked overt symptoms and functioned well but instead suffered from an "inner deadness" and an "alienation from oneself".
Paraphrasing Suzuki broadly, Fromm continues:
Buddhist psychoanalytic dialogue and integration
The dialogue between Buddhism and psychoanalysis has continued with the work of psychiatrists such as Mark Epstein, Nina Coltart, Jack Engler, Axel Hoffer, Jeremy D. Safran, David Brazier, and Jeffrey B. Rubin.
Nina Coltart (1927-1997) was the Director of the London Clinic of Psychoanalysis, a neo-Freudian and a Buddhist. She theorized that there are distinct similarities in the transformation of the self that occurs in both psychoanalysis and Buddhism. She believed that the practice of Buddhism and Psychoanalysis are "mutually reinforcing and clarifying" (Coltart, The practice of psychoanalysis and Buddhism).
Mark Epstein is an American psychiatrist who practiced Buddhism in Thailand under Ajahn Chah and has since written several books on psychoanalysis and Buddhism (Thoughts Without a Thinker 1995, Psychotherapy Without the Self, 2008). Epstein relates the Buddhist Four Noble Truths to primary narcissism as described by Donald Winnicott in his theory on the true self and false self. The first truth highlights the inevitability of humiliation in our lives of our narcissistic self-esteem. The second truth speaks of the primal thirst that makes such humiliation inevitable. The third truth promises release by developing a realistic self-image, and the fourth truth spells out the means of accomplishing that.
Jeffrey B. Rubin has also written on the integration of these two practices in Psychotherapy and Buddhism, Toward an Integration (1996). In this text, he criticizes the Buddhist idea of enlightenment as a total purification of mind: "From the psychoanalytic perspective, a static, conflict-free sphere-a psychological "safehouse" -beyond the vicissitudes of conflict and conditioning where mind is immune to various aspects of affective life such as self-interest, egocentricity, fear, lust, greed, and suffering is quixotic. Since conflict and suffering seem to be inevitable aspects of human life, the ideal of Enlightenment may be asymptotic, that is, an unreachable ideal." He points to scandals and abuses by American Buddhist teachers as examples. Rubin also outlines a case study of the psychoanalytic treatment of a Buddhist meditator and notes that meditation has been largely ignored and devalued by psychoanalysts. He argues that Buddhist meditation can provide an important contribution to the practice of psychoanalytic listening by improving an analyst's capacity for attention and recommends meditation for psychoanalysts.
Axel Hoffer has contributed to this area as editor of Freud and the Buddha, which collects several essays by psychoanalysts and a Buddhist scholar, Andrew Olendzki. Olendzki outlines an important problematic between the two systems, the Freudian practice of free association, which from the Buddhist perspective is based on: "The reflexive tendency of the mind to incessantly make a narrative of everything that arises in experience is itself the cause of much of our suffering, and meditation offers a refreshing refuge from mapping every datum of sensory input to the macro-construction of a meaningful self." Olendzki also argues that for the Buddhist, the psychoanalytic focus on linguistic narrativity distracts us from immediate experience.
David Brazier
David Brazier is a psychotherapist who combines psychotherapy and Buddhism (Zen therapy, 1995). Brazier points to various possible translations of the Pali terms of the Four Noble Truths, which give a new insight into these truths. The traditional translations of samudhaya and nirodha are "origin" and "cessation". Coupled with the translation of dukkha as "suffering", this gives rise to a causal explanation of suffering, and the impression that suffering can be totally terminated. The translation given by David Brazier gives a different interpretation to the Four Noble Truths.
Dukkha: existence is imperfect, it is like a wheel that is not straight into the axis;
Samudhaya: simultaneously with the experience of dukkha there arises tanha, thirst: the dissatisfaction with what is and the yearning that life should be different from what it is. We keep imprisoned in this yearning when we do not see reality as it is, namely imperfect and ever-changing;
Nirodha: we can confine this yearning (that reality is different from what it is), and perceive reality as it is, whereby our suffering from the imperfectness becomes confined;
Marga: this confinement is possible by following the Eightfold Path.
In this translation, samudhaya means that the uneasiness that is inherent to life arises together with the craving that life's event would be different. The translation of nirodha as confinement means that this craving is a natural reaction, which cannot be totally escaped or ceased, but can be limited, which gives us freedom.
Gestalt therapy
Gestalt Therapy, an approach created by Fritz Perls, was based on phenomenology, existentialism and also Zen Buddhism and Taoism. Perls spent some time in Japanese Zen monasteries and his therapeutic techniques include mindfulness practices and focusing on the present moment. Practices outlined by Perls himself in Ego, Hunger and Aggression (1969), such as "concentration on eating" ("we have to be fully aware of the fact that we are eating") and "awareness continuum" are strikingly similar to Buddhist mindfulness training. Other authors in Gestalt Therapy who were influenced by Buddhism are Barry Stevens (therapist) and Dick Price (who developed Gestalt Practice by including Buddhist meditation).
According to Crocker, an important Buddhist element of Gestalt is that a "person is simply allowing what-is in the present moment to reveal itself to him and out of that receptivity is responding with 'no-mind'".
More recently, Claudio Naranjo has written about the practice of Gestalt and Tibetan Buddhism.
Existential and Humanistic psychology
Both existential and humanistic models of human psychology stress the importance of personal responsibility and freedom of choice, ideas which are central to Buddhist ethics and psychology.
Humanistic psychology's focus on developing the 'fully functioning person' (Carl Rogers) and self actualization (Maslow) is similar to the Buddhist attitude of self development as an ultimate human end. The idea of person-centered therapy can also be compared to the Buddhist view that the individual is ultimately responsible for their own development, that a Buddhist teacher is just a guide and that the patient can be "a light unto themselves".
Carl Rogers's idea of "unconditional positive regard" and his stress on the importance of empathy has been compared to Buddhist conceptions of compassion (Karuṇā).
Mindfulness meditation has been seen as a way to aid the practice of person centered psychotherapy. Person centered therapist Manu Buzzano has written that "It seemed clear that regular meditation practice did help me in offering congruence, empathy and unconditional positive regard." He subsequently interviewed other person centered therapists who practiced meditation and found that it enhanced their empathy, nonjudgmental openness and quality of the relationship with their clients.
A comparison has also been made between Marshall Rosenberg's Nonviolent Communication and Buddhist ideals of right speech, both in theory and in manifesting Buddhist ideals in practice.
Padmasiri de Silva sees the focus of existential psychology on the "tragic sense of life" just a different expression of the Buddhist concept of dukkha. The existential concept of anxiety or angst as a response to the human condition also resonates with the Buddhist analysis of fear and despair. The Buddhist monk Nanavira Thera in the preface to his "Notes on Dhamma" wrote that the work of the existential philosophers offered a way to approach the Buddhist texts, as they ask the type of questions about feelings of anxiety and the nature of existence with which the Buddha begins his analysis. Nanavira also states that those who have understood the Buddha's message have gone beyond the existentialists and no longer see their questions as valid. Edward Conze likewise sees the parallel between the Buddhists and Existentialists only preliminary: "In terms of the Four Truths, the existentialists have only the first, which teaches that everything is ill. Of the second, which assigns the origin of ill to craving, they have only a very imperfect grasp. As for the third and fourth, they are quite unheard of... Knowing no way out, they are manufacturers of their own woes."
Positive psychology
The growing field of positive psychology shares with Buddhism a focus on developing a positive emotions and personal strengths and virtues with the goal of improving human well-being. Positive psychology also describes the futility of the "hedonic treadmill", the chasing of ephemeral pleasures and gains in search of lasting happiness. Buddhism holds that this very same striving is at the very root of human unhappiness.
The Buddhist concept and practice of mindfulness meditation has been adopted by psychologists such as Rick Hanson (Buddha's Brain, 2009), T.B. Kashdan & J. Ciarrochi (Mindfulness, acceptance, and positive psychology, 2013) and Itai Ivtzan (Mindfulness in Positive Psychology, 2016). Kirk W. Brown and Richard M. Ryan of the University of Pennsylvania have developed a 15-item "Mindful attention awareness scale" to measure dispositional mindfulness.
The concept of Flow studied by Mihaly Csikszentmihalyi has been compared to Buddhist meditative states such as samadhi and mindfulness. Ronald Siegel describes flow as "mindfulness while accomplishing something." Nobo Komagata and Sachiko Komagata, however, are critical of characterizing the notion of "flow" as a special case of mindfulness, noting that the connection is more complicated. Zen Buddhism has a concept called Mushin (無心, no mind) which is also similar to flow.
Christopher K. Germer, clinical instructor in psychology at Harvard Medical School and a founding member of the Institute for Meditation and Psychotherapy, has stated: "Positive psychology, which focuses on human flourishing rather than mental illness, is also learning a lot from Buddhism, particularly how mindfulness and compassion can enhance wellbeing. This has been the domain of Buddhism for the past two millennia and we're just adding a scientific perspective."
Martin Seligman and Buddhist monk Thanissaro Bhikkhu have pointed out that the framework of Positive psychology is ethically neutral, and hence within that framework, you could argue that "a serial killer leads a pleasant life, a skilled Mafia hit man leads a good life, and a fanatical terrorist leads a meaningful life." Thanissaro argues that Positive psychology should also look into the ethical dimensions of the good life. Regarding the example of flow states he writes:
The skills that Thanissaro argues are more conductive to happiness include Buddhist virtues like harmlessness, generosity, moral restraint, and the development of good will as well as mindfulness, concentration, discernment.
Naropa University
In his introduction to his 1975 book, Glimpses of the Abhidharma, Chogyam Trungpa Rinpoche wrote:
Trungpa Rinpoche's book goes on to describe the nanosecond phenomenological sequence by which a sensation becomes conscious using the Buddhist concepts of the "five aggregates".
In 1974, Trungpa Rinpoche founded the Naropa Institute, now called Naropa University. Since 1975, this accredited university has offered degrees in "contemplative psychology".
Mind and life institute
Every two years, since 1987, the Dalai Lama has convened "Mind and Life" gatherings of Buddhists and scientists. Reflecting on one Mind and Life session in March 2000, psychologist Daniel Goleman notes:
Buddhist techniques in clinical settings
For over a millennium, throughout the world, Buddhist practices have been used for non-Buddhist ends. More recently, clinical psychologists, theorists and researchers have incorporated Buddhist practices in widespread formalized psychotherapies. Buddhist mindfulness practices have been explicitly incorporated into a variety of psychological treatments. More tangentially, psychotherapies dealing with cognitive restructuring share core principles with ancient Buddhist antidotes to personal suffering.
Mindfulness practices
Fromm distinguishes between two types of meditative techniques that have been used in psychotherapy:
auto-suggestion used to induce relaxation;
meditation "to achieve a higher degree of non-attachment, of non-greed, and of non-illusion; briefly, those that serve to reach a higher level of being" (p. 50).
Fromm attributes techniques associated with the latter to Buddhist mindfulness practices.
Two increasingly popular therapeutic practices using Buddhist mindfulness techniques are Jon Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR) and Marsha M. Linehan's dialectical behavioral therapy (DBT). Other prominent therapies that use mindfulness include Steven C. Hayes' Acceptance and Commitment Therapy (ACT), Adaptation Practice founded in 1978 by the British psychiatrist and Zen Buddhist Clive Sherlock and, based on MBSR, Mindfulness-based Cognitive Therapy (MBCT) (Segal et al., 2002).
Mindfulness Based Stress Reduction (MBSR)
Kabat-Zinn developed the eight-week MBSR program over a ten-year period with over four thousand patients at the University of Massachusetts Medical Center. Describing the MBSR program, Kabat-Zinn writes:
According to Kabat-Zinn, a one-time Zen practitioner,
Kabat-Zinn describes the MBSR program, as well as its scientific basis and the evidence for its clinical effectiveness, in his 1990 book Full Catastrophe Living, which was revised and reissued in 2013.
Mindfulness-based pain management
Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness. Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism. It was developed by Vidyamala Burch and is delivered through the programs of Breathworks. It has been subject to a range of clinical studies demonstrating its effectiveness.
Dialectical Behavioral Therapy (DBT)
In writing about DBT, Zen practitioner Linehan states:
Similarly, Linehan writes:
Controlled clinical studies have demonstrated DBT's effectiveness for people with borderline personality disorder.
Acceptance and Commitment Therapy (ACT)
ACT did not explicitly emerge from Buddhism, but its concepts often parallel ideas from Buddhist and mystical traditions. ACT has been defined by its originators as a method that "uses acceptance and mindfulness processes, and commitment and behavioral activation processes to produce psychological flexibility."
Mindfulness in ACT is defined to be a combination of four aspects of the psychological flexibility model, which is ACT's applied theory:
Acceptance (openness to and engagement with present experience);
Cognitive defusion (attending to the ongoing process of thought instead of automatically interacting with events as structured by prediction, judgment, and interpretation);
Contact with the present moment (attention to the present external and internal world in a manner that is flexible, fluid, and voluntary);
A transcendent sense of self or "self as context" (an interconnected sense of consciousness that maintains contact with the "I/Here/Nowness" of awareness and its interconnection with "You/There/Then").
These four aspects of mindfulness in ACT are argued to stem from Relational Frame Theory, the research program on language and cognition that underlies ACT at the basic level. For example, "self as context" is argued to emerge from deictic verbal relations such as I/You, or Here/There, which RFT laboratories have shown to help establish perspective taking skills and interconnection with others.
Most ACT self-help books (e.g.,) and many tested ACT protocols teach formal contemplative practice skills, but by this definition of mindfulness, such defusion skills as word repetition (taking a difficult thought, distilling it to a single word, and saying it repeatedly out loud for 30 seconds) are also viewed as mindfulness methods.
Adaptation Practice
The British psychiatrist Clive Sherlock, who trained in the traditional Rinzai School of Zen, developed Adaptation Practice, the foundation of mindfulness, in 1977 based on the profound mindfulness/awareness training of Zen daily-life practice and meditation. Adaptation Practice is used for long-term relief of depression, anxiety, anger, stress and other emotional problems.
Existential Therapy
Originated from the philosophical school of existentialism, existential therapy seeks to revise the fundamental nature of human beings. Before commencing the treatment, they first ask the following question: what does it mean to be human? This then makes existential therapy distinct from other therapeutic techniques, which emphasise more on specific techniques with limited critical evaluation of their effectiveness on the subject.
This sheds light on the role Buddhism plays on psychotherapy. P. de Silva holds that Buddhist psychology is ‘’therapy oriented’’, since it not only provides an explanation for our mental ill-health and suffering, but it also offers effective treatments to them. For example, Buddhism may diagnose our anxiety, depression, and other symptoms of mental illness as stemming from greed and aversion, while encouraging us to treat them by taking the Noble Eightfold Path, developing tranquillity and insight, through the meditative practices of samatha and vipassana. Moreover, S. N. Goenka acknowledges that, the ultimate objective of undertaking Buddha’s teaching is to purify the mind, as expounded in Dhammapada 183: Abstain from unwholesome deeds,
perform wholesome deeds;
purify your own mind-
this is the teaching of the Buddhas. If so, then one shall understand that while symptoms of mental illness are often indirectly treated by practicing Buddha’s teaching, these objectives are only highly cursory and are not the main focus of the practice.
Cognitive restructuring
Dr. Albert Ellis, considered the "grandfather of cognitive-behavioral therapy" (CBT), has written:
To give but one example, Buddhism identifies anger and ill-will as basic hindrances to spiritual development (see, for instance, the Five Hindrances, Ten Fetters and kilesas). A common Buddhist antidote for anger is the use of active contemplation of loving thoughts (see, for instance, metta). This is similar to using a CBT technique known as "emotional training" which Ellis describes in the following manner:
Reaction from Buddhist traditionalists
Some traditional Buddhist practitioners have expressed concern that attempts to view Buddhism through the lens of psychology diminishes the Buddha's liberating message.
Patrick Kearney has written that the effort to integrate the teachings of the Buddha by interpreting it through the view of psychologies has led to "a growing confusion about the nature of Buddhist teachings and a willingness to distort and dilute these teachings". He is critical of Jack Kornfield and Mark Epstein for holding that psychological techniques are a necessity for some Buddhists and of Jeffrey Rubin for writing that enlightenment might not be possible. Kearney writes:
American Theravada monk Thanissaro Bhikkhu has also criticized the interpretation of Buddhism through Psychology, which has different values and goals, derived from roots such as European Romanticism and Protestant Christianity. He also identifies broad commonalities between "Romantic/humanistic psychology" and early Buddhism: beliefs in human (versus divine) intervention with an approach that is experiential, pragmatic and therapeutic. Thanissaro Bhikkhu traces the roots of modern spiritual ideals from German Romantic Era philosopher Immanuel Kant through American psychologist and philosopher William James, Jung and humanistic psychologist Abraham Maslow. Thanissaro sees their view as centered on the idea of healing the 'divided self', an idea which is alien to Buddhism. Thanissaro asserts that there are also core differences between Romantic/humanistic psychology and Buddhism. These are summarized in the adjacent table. Thanissaro implicitly deems those who impose Romantic/humanistic goals on the Buddha's message as "Buddhist Romantics".
The same similarities have been recognized by David McMahan when describing Buddhist modernism.
Recognizing the widespread alienation and social fragmentation of modern life, Thanissaro Bhikkhu writes:
Another Theravada monk, Bhikkhu Bodhi has also criticized the presentation of certain Buddhist teachings mixed with psychological and Humanistic views as being authentic Buddhism. This risks losing the essence of the liberating and radical message of the Buddha, which is focused on attaining nirvana:
Popular psychology and spirituality
Mainstream teachers and popularizers
In 1961, philosopher and professor Alan Watts wrote:
Since Watts's early observations and musings, there have been many other important contributors to the contemporary popularization of the integration of Buddhist meditation with psychology including Kornfield (1993), Joseph Goldstein, Tara Brach, Epstein (1995) and Nhat Hanh (1998).
See also
Bhavacakra
Buddhism and science
Buddhism and Western Philosophy
Buddhist philosophy
Compassion focused therapy
Eastern philosophy and clinical psychology
Health applications and clinical studies of meditation
Indian psychology
Naropa University
Notes
References
Sources and bibliography
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Linehan, M. M., H. L. Heard, & H. E. Armstrong (in press). "Naturalistic follow-up of a behavioral treatment for chronically suicidal borderline patients. Archives of General Psychiatry. Cited in Linehan (1993b).
Ñanamoli Thera (trans.) (1993). Dhammacakkappavattana Sutta: Setting Rolling the Wheel of Truth (SN 56.11). Available on-line at http://www.accesstoinsight.org/tipitaka/sn/sn56/sn56.011.nymo.html.
Nhat Hanh, Thich (1998). Mindfulness and Psychotherapy (audio). Louisville, CO: Sounds True. .
Nyanaponika Thera (1954, 1996). The Heart of Buddhist Meditation: A Handbook of Mental Training based on the Buddha's Way of Mindfulness. York Beach, ME: Samuel Weiser. .
Nyanaponika Thera, Bhikkhu Bodhi (ed.) & Erich Fromm (fwd.) (1986). Visions of Dhamma: Buddhist Writings of Nyanaponika Thera. York Beach, ME: Weiser Books. .
Rhys Davids, Caroline A. F. ([1900], 2003). Manual of Psychological Ethics, of the Fourth Century B.C., being a Translation, now made for the First Time, from the Original Pāli, of the First Book of the Abhidhamma-Piaka, entitled Dhamma-Sagai (Compendium of States or Phenomena). Whitefish, MT: Kessinger Publishing. .
Rhys Davids, Caroline A. F. (1914). Buddhist Psychology: An Inquiry into the Analysis and Theory of Mind in Pali Literature, London: Bell and sons.
Rhys Davids, Caroline A. F. (1936). Birth of Indian Psychology and its Development in Buddhism.
Sato, Koji (1958). "Psychotherapeutic Implications of Zen" in Psychologia, An International Journal of Psychology in the Orient. Vol. I, No. 4 (1958). Cited in Fromm et al. (1960).
Schwartz, Tony (1996). What Really Matters: Searching for Wisdom in America. NY: Bantam Books. .
Segal, Zindel V., J. Mark G. Williams, & John D. Teasdale (2002). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. NY: Guilford Press. .
Suzuki, D.T. & Carl G. Jung (fwd.) (1948, 1964, 1991). An Introduction to Zen Buddhism. NY: Grove Press. .
Suzuki, D.T. (1949, 1956). Zen Buddhism. NY: Doubleday Anchor Books. Cited in Ellis (1991) and Fromm (1960).
Thanissaro Bhikkhu (2012). The Roots of Buddhist Romanticism.
Varela, F. J., Thompson, E., & Rosch, E. (1991). The embodied mind: Cognitive science and human experience. Cambridge, Mass: MIT Press.
Varela, Francisco J. (ed.) (1997). Sleeping, Dreaming, and Dying: An Exploration of Consciousness with the Dalai Lama. Somerville, MA: Wisdom Publications. .
Wallace, B. A., & Shapiro, S. L. (2006). Mental balance and well-being: building bridges between Buddhism and Western psychology. American psychologist, 61(7), 690.
Watts, Alan W. (1959). The Way of Zen. NY: New American Library. Cited in Ellis (1991).
Watts, Alan W. (1960). Nature, Man and Sex. NY: New American Library. Cited in Ellis (1991).
Watts, Alan W. (1961, 1975). Psychotherapy East and West. NY: Random House. .
Zajonc, Arthur (ed.) with Zara Houshmand (2004). The New Physics and Cosmology: Dialogues with the Dalai Lama. NY: Oxford University Press. .
Related texts
Fryba, Mirko (1995). The Practice of Happiness: Exercises & Techniques for Developing Mindfulness, Wisdom, and Joy. Boston: Shambhala. .
Segal, Zindel V., J. Mark G. Williams, & John D. Teasdale (2002). Mindfulness-Based Cognitive Therapy for Depression. NY: Guilford. .
External links
Early scholarship
Rowell Havens, Teresina (1964). "Mrs. Rhys Davids' Dialogue with Psychology (1893-1924)", in Philosophy East & West. V. 14 (1964) pp. 51–58, University of Hawaii Press.
Sarunya Prasopchingchana & Dana Sugu, 'Distinctiveness of the Unseen Buddhist Identity' (International Journal of Humanistic Ideology, Cluj-Napoca, Romania, vol. 4, 2010)
Mainstream teachers and popularizers
Burns, Douglas (undated). "Buddhist Meditation and Depth Psychology"
Caveats and criticisms
"Buddhist Romanticism" a treatise by Ṭhānissaro Bhikkhu
"Buddhist Romanticism", talk by Ṭhānissaro Bhikkhu (03/25/02)
"Buddhist Romanticism Discussion", follow-up to Thanissaro Bhikkhu talk by Gil Fronsdal (04/01/02)
Psychotherapy and Buddhism
Kohut
Lorne Ladner, Positive Psychology & the Buddhist Path of Compassion
Paul C. Cooper, Attention & Inattention in Zen and Psychoanalysis
Jakob Håkansson, Exploring the phenomenon of empathy
Winnicott
Linda A. Nockler, The Spiritual and the Psychological Meet: Lessons from for Students of Awareness Practices
Daniel G. Radter, A Buddhist reinterpretation of Winnicott
FREDRIK FALKENSTRÖM, A Buddhist contribution to the psychoanalytic psychology of self
Janice Priddy, Psychotherapy and Buddhism: An Unfolding Dialogue. The Four Noble Truths in Buddhism
Bhante Kovida
Bhante Kovida An Inquiring Mind's Journey''
Psychology
Buddhist philosophy
Mindfulness (psychology)
Psychological theories
Psychology of religion
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Polysubstance dependence
|
Polysubstance dependence refers to a type of substance use disorder in which an individual uses at least three different classes of substances indiscriminately and does not have a favorite substance that qualifies for dependence on its own. Although any combination of three substances can be used, studies have shown that alcohol is commonly used with another substance. One study on polysubstance use categorized participants who used multiple substances according to their substance of preference. The results of a longitudinal study on substance use led the researchers to observe that excessively using or relying on one substance increased the probability of excessively using or relying on another substance.
Common combinations
The three substances were cocaine, alcohol, and heroin, which implies that those three are very popular. Other studies have found that opiates, cannabis, amphetamines, hallucinogens, inhalants, and benzodiazepines are often used in combination as well.
Presentation
Associated cognitive impairments
Cognition refers to what happens in the mind, such as mental functions like "perception, attention, memory, language, problem solving, reasoning, and decision making." Although many studies have looked at the cognitive impairments of individuals who are dependent on one substance, there are few researchers who have tried to determine the problems with cognitive functioning that are caused by dependence on multiple substances. Therefore, what is known about the effects of polysubstance dependence on mental abilities is based on the results of a few studies.
Learning ability
The effect of polysubstance dependence on learning ability is one area of interest to researchers. A study involving 63 polysubstance dependent women and 46 controls (participants who were not using substances) used the Benton Visual Retention Test (BVRT) and the California Verbal Learning Test (CVLT) to look at visual memory and verbal ability. This study showed that in polysubstance dependent women, verbal learning ability was significantly decreased, though visual memory was not affected. In addition, alcohol and cocaine use led to more severe issues with verbal learning, recall, and recognition.
Memory, reasoning and decision making
Sometimes studies about specific groups in the general population can be informative. One study decided to test the cognitive abilities of participants in rave parties who used multiple substances. To do this, they compared 25 rave party attenders with 27 control participants who were not using substances. The results of this study indicated that in general, the rave attender group did not perform as well on tasks that tested speed of information processing, working memory, knowledge of similarities between words, ability to attend to a task with interference in the background, and decision making. Certain substances were associated with particular mental functions, but the researchers suggested that the impairments for working memory and reasoning were caused by the misuse of multiple substances.
Another study that tried to find differences between the effects of particular substances focused on people with polysubstance use who were seeking treatment for addictions to cannabis, cocaine, and heroin. They studied a group of people with polysubstance use and a group that was not dependent on any substances. Because alcohol was a common co-substance for nearly all of the people in the polysubstance use group, it was difficult to tell exactly which substances were affecting certain cognitive functions. The researchers found that the difference in the two groups' performance levels on executive function, or higher-level cognitive processing tasks were consistently showing that the polysubstance group scored lower than the control group. In general, this meant that multiple substances negatively affected the polysubstance group's cognitive functioning. More specifically, the researchers found that the amount of cannabis and cocaine affected the verbal part of working memory, the reasoning task, and decision making, while cocaine and heroin had a similar negative effect on visual and spatial tasks, but cannabis particularly affected visual and spatial working memory. These results suggest that the combined use of cannabis, cocaine, and heroin impair more cognitive functions more severely than if used separately.
Alcohol's negative effects on learning, spatial abilities and memory has been shown in many studies. This raises a question: does using alcohol in combination with other substances impair cognitive functioning even more? One study decided to try to determine if people with polysubstance use who also recreationally use alcohol would display poorer performance on a verbal learning and memory test in comparison to those who consumed excessive amounts of alcohol specifically. The California Verbal Learning Test (CVLT) was used due to its ability to "quantify small changes in verbal learning and memory" by evaluating errors made during the test and the strategies used to make those errors. The results of this study showed that the group of people with polysubstance and alcohol use performed poorly on the CVLT recall and recognition tests compared to the group of people who exclusively consumed excessive alcohol only, which implies that polysubstance use impaired the memory and learning in a different way than the effects of alcohol alone can explain.
Length of abstinence matter
To examine whether abstinence for long periods of time helps people with polysubstance use recover their cognitive function, a group of researchers tested 207 polysubstance dependent men, of whom 73.4% were dependent on three or more substances. The researchers were interested in six areas of cognitive functioning, which included visual memory, verbal memory, knowledge of words, abstract reasoning, inhibition (interference), and attention. The study used the Benton Visual Retention Test (BVRT) for testing visual memory, the California Verbal Learning Test (CVLT) for verbal memory, the Wechsler Adult Intelligence Scale vocabulary portion for knowledge of words, the Booklet Category Test for abstract reasoning, the Stroop Neuropsychological Screening task for inhibition, and the Trail Making Test for attention. The results showed that neuropsychological ability did not improve with increases in the length of time abstinent. This suggests that polysubstance dependence leads to serious impairment which cannot be recovered much over the span of a year.
Causes
Biological
There is data to support that some genes contribute to substance dependence. Some studies have focused on finding genes that predispose the person to be dependent on marijuana, cocaine, or heroin by studying genes that control a person's dopamine and opioid receptors, but no conclusive findings were reported. Other researchers found a connection between dopamine receptor genes and dependency on a substance. A potential problem with this study was that alcohol is commonly used with another substance, so the results of the study may not have been caused by dependency on a single substance. This means that multiple substances may have been contributing to the results, but the researchers suggested that further research should be done.
However, there are studies that have found evidence of the influence of genes on vulnerability to substance dependence. These studies often use genotype, or the genetic information found on a person's chromosomes, and phenotype, which consists of the visible features of a person, to look at genetic patterns. One study examined the phenotype and genotype of 1,858 participants from 893 families to look at differences in three nicotinic acetylcholine receptor genes found within these individuals. The experimenters found significant connections between receptor genes for nicotine and polysubstance dependence, which indicated that differences in these genes can create the risk of being dependent on multiple substances.
Psychological
A 1985 study conducted by Khantzian and Treece found that 65% of their opioid-dependent sample met criteria for a personality disorder diagnosis. In the same study, 93% of the sample had a comorbid disorder, implying that the comorbid disorder plays some role in the addiction. It has also been shown that depression and polysubstance dependence are often both present at the same time. If a person is genetically predisposed to be depressed then they are at a higher risk of having polysubstance dependence.
Possibly the most widely accepted cause of addictions is the self-medication hypothesis, that views substance addiction as a form of coping with stress through negative reinforcement, by temporarily alleviating awareness of or concerns over the stressor. People who use substances learn that the effects of each type of substance works to relieve or better painful states. They use substances as a form of self-medication to deal with difficulties of self-esteem, relationships, and self-care. Individuals with substance use disorders often are overwhelmed with emotions and painful situations and turn to substances as a coping method.
Sociocultural
The sociocultural causes are areas in a person's life that might have influenced their decision to start and continue using multiple substances. Sociocultural causes can be divided into social causes and cultural causes.
Social Causes: Some studies have shown that adolescents have one of the highest rates of polysubstance dependence. According to one study this population, ages 12–25, represents about half of the nation's population that uses illicit substances. Of these individuals, half of them have started using substances by the end of 12th grade. This could be attributed to social expectations of peers, peer pressure to fit in, or a way of numbing their emotions. Some of these young kids start trying different substances initially to fit in, but then after a while they start to develop a tolerance for these substances and experience withdrawal if they don't have enough substances in their system and eventually become dependent on having the effects of substance dependence. With tolerance comes the craving for additional substances to get high, this constant need for that feeling is polysubstance dependence.
In the older generations, polysubstance dependence had been linked to additional considerations such as personality disorder, homelessness, bipolar disorder, major depressive disorder and so on. Medical care being so expensive and difficult to get long term has been linked to polysubstance dependence. Those who need psychological help sometimes use multiple substances as a type of self medication to help manage their mental illnesses.
Comorbidity of mental disorders
For most of these disorders, in relation to polysubstance dependence, there is a vicious cycle that those with a dependence go through. First, ingesting the substance creates a need for more, which creates a dopamine surge, which then creates pleasure. As the dopamine subsides, the pleasure adds to the emotional and physical pain and triggers stress transmitters, which in turn creates a craving, which must then be medicated, and thus the cycle begins again. However, the next time they use, more of the substance will need to be used to get to the same degree of intoxication .
Depression
Scientists have hypothesized that the use of a substance either causes a mood disorder such as depression or at least attributes to a pre-existing one. Additionally, the substances that people with depression use can be a misguided method of self-medication in order to manage their depression. This is the classic chicken or egg hypothesis, does the pre-existing condition cause dependence or does dependence cause the condition? The underlying mental illness needs to be identified and treated in conjunction with treating the polysubstance dependence in order to increase the success rate of treatment and decrease the probability of relapse. One specific study focused on alcohol and depression, because they are so commonly inter-related. Researchers have discovered that depression continues for several weeks after a patient had been rehabilitated and those who relapsed developed depression again. This means that the onset of depression happens after alcohol dependence occurs, which means that alcohol is a major contributor to depression.
Eating disorders
One study showed that patients who are recovering from an addiction, who have had an eating disorder in the past, often use food to try to replace the substance that they are no longer getting. Or they obsess over controlling their weight and appearance. Some rehabilitation centers have licensed nutritionists to help patients develop healthy eating habits to help them cope while recovering from their addictions. It is important that those who have a former eating disorder be taught how to eat healthfully, so they don't continuously switch from one addiction back to another.
Diagnosis
According to the DSM-IV, a diagnosis of polysubstance dependence must include a person who has used at least three different substances (not including caffeine or nicotine) indiscriminately, but does not have a preference to any specific one. In addition they must show a minimum of three of the following symptoms listed below, all within the past twelve months. There is a distinct difference between a person having three separate dependence issues and having Polysubstance dependence the main difference is polysubstance dependence means that they are not specifically addicted to one particular substance. This is often confused with multiple specific dependences present at the same time. To elaborate, if a person is addicted to three separate substance such as cocaine, methamphetamines and alcohol and is dependent on all three then they would be diagnosed with three separate dependence disorders existing together (cocaine dependence, methamphetamine dependence and alcohol dependence,) not polysubstance dependence. In addition to using three different substances without a preference to one, there has to be a certain level of dysfunction in a person's life to qualify for a diagnosis of polysubstance dependence. One of the bigger challenges that often occurs when trying to diagnose is the fact that people don't always report what they are taking because they are afraid of getting into legal trouble. When coding polysubstance Dependence in a DSM-IV it would be a multiaxial diagnosis 304.80- Polysubstance Dependence", next to the classification, it is accompanied by a list of other types of Substance dependence (e.g. "305.00 Alcohol Abuse" or "305.60 Cocaine Abuse").
The DSM-IV requires at least three of the following symptoms present during a 12-month period for a diagnoses of polysubstance dependence.
Tolerance: Use of increasingly high amounts of a substance or they find the same amount less and less effective ( the amount has to be at least 50% more of the original amount needed.)
Withdrawal: Either withdrawal symptoms when the substance stops being used or the substance is used to prevent withdrawal symptoms.
Loss of control: Repeated use of more substance than was initially planned or use of the substances over longer periods of time than was planned.
Inability to stop using: Either unsuccessfully attempted to cut down or stop using the substances or a persistent desire to stop using.
Time: Spending a lot of time studying substances, obtaining substances, using substances, being under the influence of substances, and recovering from the effects of substances.
Interference with activities: Give up or reduce the amount of time involved in recreational activities, social activities, and/or occupational activities because of the use of substances.
Harm to self: Continuous use of substances despite having a physical or psychological problem caused by or made worse by the use of substances.
DSM-5 eliminated polysubstance disorder; there the substances must be specified, among other related changes.
Treatment
Treatment for polysubstance dependence has many critical aspects. Substance rehabilitation is a lengthy and difficult process. Treatment must be individualized and last a sufficient amount of time to ensure the patient has kicked the addictions and to ensure the prevention of relapse. The most common forms of treatment for polysubstance dependence include: inpatient and outpatient treatment centers, counseling and behavioral treatments, and medications. It is important that treatments be carried on throughout the patient's life in order to prevent relapse. It is a good idea that recovering addicts continue to attend social support groups or meet with counselors to ensure they do not relapse.
Inpatient treatment center
Inpatient treatment centers are treatment centers where addicts move to the facility while they are undergoing treatment. Inpatient treatment centers offer a safe environment where patients will not be exposed to potentially harmful situations during their treatments as they would on the outside. Inpatients usually undergo the process of detoxification. Detox involves withdrawing the user (usually medically) from all substances of concern. During their stay in the treatment facility, patients often are learning to manage and identify their substance addictions and to find alternate ways to cope with whatever is the cause of their addiction.
Outpatient treatments
Outpatient treatments include many of the same activities offered in an inpatient treatment facility, but the patient is not protected by the secure and safe environment of an inpatient treatment center. For this reason, they are significantly less effective. The patient usually continues to hold a job and goes to treatment nightly.
Twelve-step programs
Both in-patient and out-patient treatments can offer introductions to Twelve-step programs such as Alcoholics Anonymous and Narcotics Anonymous. They offer regular meetings where members can discuss their experiences in a non-judgmental and supportive place.
Cognitive behavioral therapy
Also offered to patients are one-on-one counseling sessions and cognitive behavioral therapy (CBT). When looked at through a cognitive-behavioral perspective, addictions are the result of learned behaviors developed through positive experiences. In other words, when an individual uses a substance and receives desired results (happiness, reduced stress, etc.) it may become the preferred way of attaining those results, leading to addictions. The goal of CBT is to identify the needs that the addictions are being used to meet and to develop skills and alternative ways of meeting those needs. The therapist will work with the patient to educate them on their addictions and give them the skills they need to change their cognitions and behaviors. Addicts will learn to identify and correct problematic behavior. They will be taught how to identify harmful thoughts and substance cravings. CBT is an effective treatment for addictions.
Medications
Medications can be very helpful in the long-term treatment of polysubstance dependence. Medications are a useful aid in helping to prevent or reducing substance cravings. Another benefit of medications is helping to preventing relapse. Since substance use disorders affect brain functioning, medications assist in returning to normal brain functioning. People who use multiple substances require medications for each substance they use, as the current medications do not treat all substance use disorders simultaneously. Medications are a useful aid in treatments, but are not effective when they are the sole treatment method.
Substance use Disorder Medications
Methadone treatment for heroin addiction.
Naltrexone: Reduces opiates and alcohol cravings.
Disulfiram: induces intense nausea after drinking alcohol.
Acamprosate: normalizes brain chemistry disrupted by alcohol withdrawal and aids alcohol abstinence.
Buprenorphine/naloxone: The two medications together reduce cravings and block the pleasure from opiates.
Epidemiology
There are not very many studies that have examined how often polysubstance dependence occurs or how many people are dependent on multiple substances. However, according to a study that analyzed the results from the National Epidemiological Survey on Alcohol and Related Conditions, approximately 215.5 out of a total of 43,093 individuals in the United States (0.5%) met the requirements for polysubstance use disorder. Another study suggested that the number of new cases of polysubstance dependence has been going up. This idea was supported by a study that took place in Munich, Germany. A group of researchers chose to look at responses to a survey using the M-Composite International Diagnostic Interview (M-CIDI). The M-CIDI is a version of the Composite International Diagnostic Interview (CIDI). The researchers collected data from 3,021 participants, all between the ages of 14 and 24, to estimate the prevalence, or total number of cases, of substance use and of polysubstance use/dependence. The results of this study indicated that of the 17.3% who said that they regularly used substances, 40% said that they used more than one substance, but 3.9% specifically reported using three or more substances, indicating that there is a lot of overlap in the use of different substances. The researchers compared their results to earlier German studies and found that substance dependence seems to be increasing, at least in Germany.
Gender differences
Women and men differ in various ways when it comes to addictions. Research has shown that women are more likely to be polysubstance dependent. It has been noted that a larger percentage of women use licit (legal) substances such as tranquilizers, sedatives, and stimulants. On the other hand, men are more likely to use illicit (illegal) substances such as cocaine, methamphetamine, and other illicit substances. Research suggests that women addicts more frequently have a family history of substance use. When asked to describe their onset of addictions, women more frequently describe their addiction as sudden where as men describe them as gradual. Females have a higher percentage of fatty tissues and a lower percentage of body water than men. Therefore, women absorb substances more slowly. This means these substances are at a higher concentration in a woman's bloodstream. Female addicts are known to be at greater risk for fatty liver disease, hypertension, anemia, and other disorders.
See also
Self-medication
References
External links
A great resource for more information: http://www.nida.nih.gov/nidahome.html
Clinical pharmacology
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Patient education
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Patient education is a planned interactive learning process designed to support and enable expert patients to manage their life with a disease and/or optimise their health and well-being.
Overview
Education may be provided by any healthcare professional who has undertaken appropriate training education, education on patient communication and education is usually included in the healthcare professional's training. However, further training is required to develop specialist skills needed to facilitate self-management and behaviour change. Patient Education can often be more effective in Patient comprehension that things such as medication guides. Many institutions are calling for courses in educating medical students in Technical Communication to promote Patient Education and the subsequent benefits thereof.
Health education is also a tool used by managed care plans, and may include both general preventive education or health promotion and disease or condition specific education. Some topics proposed in Patient Education courses include Technical and Professional Communication (TPC) and Rhetoric of Health and Medicine (RHM) in order to prepare Health educators to create simple and culturally sensitive avenues of communication.
Benefits
Important elements of patient education are skill building and responsibility: patients need to know when, how, and why they need to make a lifestyle change. Group effort is equally important: each member of the patient's health care team needs to be involved. It can also help the patients by a better lifestyle, it gives them the ability to learn new information.
The value of patient education can be summarized as follows:
Improved understanding of medical condition, diagnosis, disease, or disability.
Improved understanding of methods and means to manage multiple aspects of medical condition.
Improved self-advocacy in deciding to act both independently from medical providers and in interdependence with them.
Improved initiative in voicing concerns over medication delivery, risks, and dosages with a physician.
Improve trust between a patient and their provider through effective and clear communication.
Increased adherence – Effective communication and patient education increases patient motivation to adhere to treatments.
Patient outcomes – Patients more likely to respond well to their treatment plan – fewer complications.
Informed consent – Patients feel you've provided the information they need to make informed decisions
Empowered to make shared decision - Patients understanding of the evidence of benefits and risks of interventions, helps them to truly weigh the trade-offs they are (un)willing to make.
Increased health literacy and confidence to navigate the health systems.
Utilization – More effective use of medical services – fewer unnecessary phone calls and visits.
Satisfaction and referrals – Patients more likely to stay with your practice and refer other patients.
Risk Management – Lower risk of malpractice when patients have realistic expectations.
Race and health – Target education to help reduce the disproportionate burden on populations at increase risk of mortailty.
Health Educators
The competencies of a health educator include the following:
Incorporate a personal ethic in regards to social responsibilities and services towards others.
Provide accurate, competent, and evidence-based care.
Practice preventive health care.
Focus on relationship-centered care with individuals and their families.
Incorporate the multiple determinants of health when providing care.
Be culturally sensitive and be open to a diverse society.
Use technology appropriately and effectively.
Be current in the field and continue to advance education.
Outcomes
There are many areas where patient education can improve the outcomes of treatment.
For example, in patients with amputations, patient education has been shown to be effective when approached from all angles by the healthcare team (nurse, primary care physician, prosthetist, physical therapist, occupational therapist etc.). Support groups have been shown to be a helpful method for dealing with depression in this population. Preoperative patient education helped patients with their decision-making process by informing them of factors related to pain, limb loss, and functional restriction faced after amputation.
In the case of arthritis, patient education was found to be administered through three methods, including individual face to face meetings with healthcare professionals, patient groups, online support programs. Category I evidence was found for individual, face to face counselling. Meeting with rheumatologists, occupational therapists, physical therapists, nurses, and other healthcare providers was found to be effective in creating adherence to treatment, medication, and for improving overall patient health.
In the case of rheumatoid arthritis, patient education has been shown as an effective non-pharmacological treatment. It is recommended that patient education should be the start point and underpin all self-management interventions.
The role of patient organisations in providing support and structured guidance for people with arthritis is widely valued by professionals and patients.
It is important to consider patient factors that may help improve outcomes of patient education patient. These are patient activation, illness perceptions, anxiety, participants' knowledge about their condition, engagement with routine check-ups and positive health behaviours. These factors may be also be targets for patient education.
See also
Expert Patient Programme
Compliance (medicine)
Cultural competence in healthcare
Green prescription
Managed care
Medical writing
Orem model of nursing
Footnotes
References
Cordier JF. The expert patient: towards a novel definition. Eur Respir J. 2014 Oct;44(4):853-7. doi: 10.1183/09031936.00027414. PMID 25271227
Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills
London, F. (2009). No Time To Teach: The Essence of Patient and Family Education for Health Care Providers. Atlanta: Pritchett & Hull
Rankin, S. H., Stallings, K. D., & London, F. (2005). Patient Education in Health and Illness (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins
Bastable, S.B, Grambet, P., Jacobs, K., Sopczyk, D.L. (2011). Health professionals as educator: Principles of teaching and learning. Sudbury, MA: Jones & Bartlett Learning, LLC.
Public health education
Health education
Patient
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Verbal Behavior
|
Verbal Behavior is a 1957 book by psychologist B. F. Skinner, in which he describes what he calls verbal behavior, or what was traditionally called linguistics. Skinner's work describes the controlling elements of verbal behavior with terminology invented for the analysis - echoics, mands, tacts, autoclitics and others - as well as carefully defined uses of ordinary terms such as audience.
Origins
The origin of Verbal Behavior was an outgrowth of a series of lectures first presented at the University of Minnesota in the early 1940s and developed further in his summer lectures at Columbia and William James lectures at Harvard in the decade before the book's publication.
Research
Skinner's analysis of verbal behavior drew heavily on methods of literary analysis. This tradition has continued. The book Verbal Behavior is almost entirely theoretical, involving little experimental research in the work itself. Many research papers and applied extensions based on Verbal Behavior have been done since its publication.
Functional analysis
Skinner's Verbal Behavior also introduced the autoclitic and six elementary operants: mand, tact, audience relation, echoic, textual, and intraverbal. For Skinner, the proper object of study is behavior itself, analyzed without reference to hypothetical (mental) structures, but rather with reference to the functional relationships of the behavior in the environment in which it occurs. This analysis extends Ernst Mach's pragmatic inductive position in physics, and extends even further a disinclination towards hypothesis-making and testing. Verbal Behavior is divided into 5 parts with 19 chapters. The first chapter sets the stage for this work, a functional analysis of verbal behavior. Skinner presents verbal behavior as a function of controlling consequences and stimuli, not as the product of a special inherent capacity. Neither does he ask us to be satisfied with simply describing the structure, or patterns, of behavior. Skinner deals with some alternative, traditional formulations, and moves on to his own functional position.
General problems
In the ascertaining of the strength of a response Skinner suggests some criteria for strength (probability): emission, energy-level, speed, and repetition. He notes that these are all very limited means for inferring the strength of a response as they do not always vary together and they may come under the control of other factors. Emission is a yes/no measure, however the other three—energy-level, speed, repetition—comprise possible indications of relative strength.
Emission – If a response is emitted it may tend to be interpreted as having some strength. Unusual or difficult conditions would tend to lend evidence to the inference of strength. Under typical conditions it becomes a less compelling basis for inferring strength. This is an inference that is either there or not, and has no gradation of value.
Energy-level – Unlike emission as a basis for inference, energy-level (response magnitude) provides a basis for inferring the response has a strength with a high range of varying strength. Energy level is a basis from which we can infer a high tendency to respond. An energetic and strong "Water!" forms the basis for inferring the strength of the response as opposed to a weak, brief "Water".
Speed – Speed is the speed of the response itself, or the latency from the time in which it could have occurred to the time in which it occurs. A response given quickly when prompted forms the basis for inferring a high strength.
Repetition – "Water! Water! Water!" may be emitted and used as an indication of relative strength compared to the speedy and/or energetic emission of "Water!". In this way repetition can be used as a way to infer strength.
Mands
Chapter Three of Skinner's work Verbal Behavior discusses a functional relationship called the mand. Mand is verbal behavior under functional control of satiation or deprivation (that is, motivating operations) followed by characteristic reinforcement often specified by the response. A mand is typically a demand, command, or request. The mand is often said to "describe its own reinforcer" although this is not always the case, especially as Skinner's definition of verbal behavior does not require that mands be vocal. A loud knock at the door, may be a mand "open the door" and a servant may be called by a hand clap as much as a child might "ask for milk".
Lamarre & Holland (1985) study on mands demonstrated the role of motivating operations. The authors contrived motivating operations for objects by training behavior chains that could not be completed without certain objects. The participants learned to mand for these missing objects, which they had previously only been able to tact...
Behavior under the control of verbal stimuli
Textual
In Chapter Four Skinner notes forms of control by verbal stimuli. One form is textual behavior which refers to the type of behavior we might typically call reading or writing. A vocal response is controlled by a verbal stimulus that is not heard. There are two different modalities involved ("reading"). If they are the same they become "copying text" (see Jack Michael on copying text), if they are heard, then written, it becomes "taking dictation", and so on.
Echoic
Skinner was one of the first to seriously consider the role of imitation in language learning. He introduced this concept into his book Verbal Behavior with the concept of the echoic. It is a behavior under the functional control of a verbal stimulus. The verbal response and the verbal stimulus share what is called point to point correspondence (a formal similarity.) The speaker repeats what is said. In echoic behavior, the stimulus is auditory and response is vocal. It is often seen in early shaping behavior. For example, in learning a new language, a teacher might say "parsimonious" and then say "can you say it?" to induce an echoic response. Winokur (1978) is one example of research about echoic relations.
Tacts
Chapter Five of Verbal Behavior discusses the tact in depth. A tact is said to "make contact with" the world, and refers to behavior that is under functional control of a non-verbal stimulus and generalized conditioned reinforcement. The controlling stimulus is nonverbal, "the whole of the physical environment". In linguistic terms, the tact might be regarded as "expressive labelling". Tact is the most useful form of verbal behaviour to other listeners, as it extends the listeners contact with the environment. In contrast, the tact is the most useful form of verbal behaviour to the speaker as it allows to contact tangible reinforcement.
Tacts can undergo many extensions: generic, metaphoric, metonymical, solecistic, nomination, and "guessing". It can also be involved in abstraction. Lowe, Horne, Harris & Randle (2002) would be one example of recent work in tacts.
Intraverbal
Intraverbals are verbal behavior under the control of other verbal behavior. Intraverbals are often studied by the use of classic association techniques.
Audiences
Audience control is developed through long histories of reinforcement and punishment. Skinner's three-term contingency can be used to analyze how this works: the first term, the antecedent, refers to the audience, in whose presence the verbal response (the second term) occurs. The consequences of the response are the third term, and whether or not those consequences strengthen or weaken the response will affect whether that response will occur again in the presence of that audience. Through this process, audience control, or the probability that certain responses will occur in the presence of certain audiences, develops. Skinner notes that while audience control is developed due to histories with certain audiences, we do not have to have a long history with every listener in order to effectively engage in verbal behavior in their presence (p. 176). We can respond to new audiences (new stimuli) as we would to similar audiences with whom we have a history.
Negative audiences
An audience that has punished certain kinds of verbal behavior is called a negative audience (p. 178): in the presence of this audience, the punished verbal behavior is less likely to occur. Skinner gives examples of adults punishing certain verbal behavior of children, and a king punishing the verbal behavior of his subjects.
Summary of verbal operants
The following table summarizes the new verbal operants in the analysis of verbal behavior.
Verbal operants as a unit of analysis
Skinner notes his categories of verbal behavior: mand, textual, intraverbal, tact, audience relations, and notes how behavior might be classified. He notes that form alone is not sufficient (he uses the example of "fire!" having multiple possible relationships depending on the circumstances). Classification depends on knowing the circumstances under which the behavior is emitted. Skinner then notes that the "same response" may be emitted under different operant conditions. Skinner states:
That is, classification alone does little to further the analysis—the functional relations controlling the operants outlined must be analyzed consistent with the general approach of a scientific analysis of behavior.
Multiple causation
Skinner notes in this chapter how any given response is likely to be the result of multiple variables. Secondly, that any given variable usually affects multiple responses. The issue of multiple audiences is also addressed, as each audience is, as already noted, an occasion for strong and successful responding. Combining audiences produces differing tendencies to respond.
Supplementary stimulation
Supplementary stimulation is a discussion to practical matters of controlling verbal behavior given the context of material which has been presented thus far. Issues of multiple control, and involving many of the elementary operants stated in previous chapters are discussed.
New combinations of fragmentary responses
A special case of where multiple causation comes into play creating new verbal forms is in what Skinner describes as fragmentary responses. Such combinations are typically vocal, although this may be due to different conditions of self-editing rather than any special property. Such mutations may be "nonsense" and may not further the verbal interchange in which it occurs. Freudian slips may be one special case of fragmentary responses which tend to be given reinforcement and may discourage self-editing. This phenomenon appears to be more common in children, and in adults learning a second language. Fatigue, illness and insobriety may tend to produce fragmentary responding.
Autoclitics
An autoclitic is a form of verbal behavior which modifies the functions of other forms of verbal behavior. For example, "I think it is raining" possesses the autoclitic "I think" which moderates the strength of the statement "it is raining". An example of research that involved autoclitics would be Lodhi & Greer (1989).
Self-strengthening
Here Skinner draws a parallel to his position on self-control and notes: "A person controls his own behavior, verbal or otherwise, as he controls the behavior of others." Appropriate verbal behavior may be weak, as in forgetting a name, and in need of strengthening. It may have been inadequately learned, as in a foreign language. Repeating a formula, reciting a poem, and so on. The techniques are manipulating stimuli, changing the level of editing, the mechanical production of verbal behavior, changing motivational and emotional variables, incubation, and so on. Skinner gives an example of the use of some of these techniques provided by an author.
Logical and scientific
The special audience in this case is one concerned with "successful action". Special methods of stimulus control are encouraged that will allow for maximum effectiveness. Skinner notes that "graphs, models, tables" are forms of text that allow for this kind of development. The logical and scientific community also sharpens responses to assure accuracy and avoid distortion. Little progress in the area of science has been made from a verbal behavior perspective; however, suggestions of a research agenda have been laid out.
Tacting private events
Private events are events accessible to only the speaker. Public events are events that occur outside of an organism's skin that are observed by more than one individual. A headache is an example of a private event and a car accident is an example of a public event.
The tacting of private events by an organism is shaped by the verbal community who differentially reinforce a variety of behaviors and responses to the private events that occur (Catania, 2007, p. 9). For example, if a child verbally states, "a circle" when a circle is in the immediate environment, it may be a tact. If a child verbally states, "I have a toothache", she/he may be tacting a private event, whereas the stimulus is present to the speaker, but not the rest of the verbal community.
The verbal community shapes the original development and the maintenance or discontinuation of the tacts for private events (Catania, 2007, p. 232). An organism responds similarly to both private stimuli and public stimuli (Skinner, 1957, p. 130). However, it is harder for the verbal community to shape the verbal behavior associated with private events (Catania, 2007, p. 403). It may be more difficult to shape private events, but there are critical things that occur within an organism's skin that should not be excluded from our understanding of verbal behavior (Catania, 2007, p. 9).
Several concerns are associated with tacting private events. Skinner (1957) acknowledged two major dilemmas. First, he acknowledges our difficulty with predicting and controlling the stimuli associated with tacting private events (p. 130). Catania (2007) describes this as the unavailability of the stimulus to the members of the verbal community (p. 253). The second problem Skinner (1957) describes is our current inability to understand how the verbal behavior associated with private events is developed (p. 131).
Skinner (1957) continues to describe four potential ways a verbal community can encourage verbal behavior with no access to the stimuli of the speaker. He suggests the most frequent method is via "a common public accompaniment". An example might be that when a kid falls and starts bleeding, the caregiver tells them statements like, "you got hurt". Another method is the "collateral response" associated with the private stimulus. An example would be when a kid comes running and is crying and holding their hands over their knee, the caregiver might make a statement like, "you got hurt". The third way is when the verbal community provides reinforcement contingent on the overt behavior and the organism generalizes that to the private event that is occurring. Skinner refers to this as a "metaphorical or metonymical extension". The final method that Skinner suggests may help form our verbal behavior is when the behavior is initially at a low level and then turns into a private event (Skinner, 1957, p. 134). This notion can be summarized by understanding that the verbal behavior of private events can be shaped through the verbal community by extending the language of tacts (Catania, 2007, p. 263).
Private events are limited and should not serve as "explanations of behavior" (Skinner, 1957, p. 254). Skinner (1957) continues to caution that, "the language of private events can easily distract us from the public causes of behavior" (see functions of behavior).
Chomsky's review and replies
In 1959, Noam Chomsky published an influential critique of Verbal Behavior. Chomsky pointed out that children acquire their first language without being explicitly or overtly "taught" in a way that would be consistent with behaviorist theory (see Language acquisition and Poverty of the stimulus), and that Skinner's theories of "operants" and behavioral reinforcements are not able to account for the fact that people can speak and understand sentences that they have never heard before.
According to Frederick J. Newmeyer:
Chomsky's review has come to be regarded as one of the foundational documents of the discipline of cognitive psychology, and even after the passage of twenty-five years it is considered the most important refutation of behaviorism. Of all his writings, it was the Skinner review which contributed most to spreading his reputation beyond the small circle of professional linguists.
Chomsky's 1959 review, amongst his other work of the period, is generally thought to have been influential in the decline of behaviorism's influence within linguistics, philosophy and cognitive science. One reply to it was Kenneth MacCorquodale's 1970 paper On Chomsky's Review of Skinner's Verbal Behavior. MacCorquodale argued that Chomsky did not possess an adequate understanding of either behavioral psychology in general, or the differences between Skinner's behaviorism and other varieties. As a consequence, he argued, Chomsky made several serious errors of logic. On account of these problems, MacCorquodale maintains that the review failed to demonstrate what it has often been cited as doing, implying that those most influenced by Chomsky's paper probably already substantially agreed with him. Chomsky's review has been further argued to misrepresent the work of Skinner and others, including by taking quotes out of context. Chomsky has maintained that the review was directed at the way Skinner's variant of behavioral psychology "was being used in Quinean empiricism and naturalization of philosophy".
Current research
Current research in verbal behavior is published in The Analysis of Verbal Behavior (TAVB), and other Behavior Analytic journals such as The Journal of the Experimental Analysis of Behavior (JEAB) and the Journal of Applied Behavior Analysis (JABA). Also research is presented at poster sessions and conferences, such as at regional Behavior Analysis conventions or Association for Behavior Analysis (ABA) conventions nationally or internationally. There is also a Verbal Behavior Special Interest Group (SIG) of the Association for Behavior Analysis (ABA) which has a mailing list.
Journal of Early and Intensive Behavior Intervention and the Journal of Speech-Language Pathology and Applied Behavior Analysis both publish clinical articles on interventions based on verbal behavior.
Skinner has argued that his account of verbal behavior might have a strong evolutionary parallel. In Skinner's essay, Selection by Consequences he argued that operant conditioning was a part of a three-level process involving genetic evolution, cultural evolution and operant conditioning. All three processes, he argued, were examples of parallel processes of selection by consequences. David L. Hull, Rodney E. Langman and Sigrid S. Glenn have developed this parallel in detail. This topic continues to be a focus for behavior analysts. Behavior analysts have been working on developing ideas based on Verbal Behaviour for fifty years, and despite this, experience difficulty explaining generative verbal behavior.
See also
The Analysis of Verbal Behavior
Applied behavior analysis
Child development
Experimental analysis of behavior
Functional analytic psychotherapy
Jack Michael
Reinforcement
Relational frame theory
References
External links
An Introduction to Verbal Behavior Online Tutorial
Chomsky's 1959 Review of Verbal Behavior
On Chomsky's Appraisal of Skinner's Verbal Behavior: A Half Century of Misunderstanding
The Analysis of Verbal Behavior pubmed archive
abainternational.org
contextualpsychology.org
ironshrink.com
A Tutorial of B.F. Skinner's Verbal Behavior (1957)
Psychology books
Linguistics books
1957 non-fiction books
Behaviorism
Cognitive science literature
Works by B. F. Skinner
History of psychology
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Modified Rankin Scale
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The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It has become the most widely used clinical outcome measure for stroke clinical trials.
The scale was originally introduced in 1957 by Dr. John Rankin of Stobhill Hospital, Glasgow, Scotland as a 5-level scale ranging from 1 to 5. It was then modified by either van Swieten et al. or perhaps Prof. C. Warlow's group at Western General Hospital in Edinburgh for use in the UK-TIA study in the late 1980s to include the value '0' for patients who had no symptoms. As late as 2005 the scale was still being reported as ranging from 0 to 5. Somewhere between 2005 and 2008 the final change was made to add the value '6' to designate patients who had died. The modern version of modified version differs from Rankin's original scale mainly in the addition of grade 0, indicating a lack of symptoms, and the addition of grade 6 indicating dead.
Interobserver reliability of the mRS can be improved by using a structured questionnaire during the interview process and by having raters undergo a multimedia training process. The multimedia mRS training system which was developed by Prof. K. Lees' group at the University of Glasgow is available online. The mRS is frequently criticized for its subjective nature which is viewed as skewing results, but is used throughout hospital systems to assess rehabilitation needs and outpatient course. These criticisms were addressed by researchers creating structured interviews which ask simple questions both the patient and/or the caregiver can respond to.
More recently, several tools have been developed to more systematically determine the mRS, including the mRS-SI, the RFA, and the mRS-9Q. The mRS-9Q is in the public domain and free web calculators are available at modifiedrankin.com and mdcalc.com.
The Modified Rankin Scale (mRS)
The scale runs from 0–6, running from perfect health without symptoms to death.
0 - No symptoms.
1 - No significant disability. Able to carry out all usual activities, despite some symptoms.
2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.
3 - Moderate disability. Requires some help, but able to walk unassisted.
4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.
5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
6 - Dead.
See also
Barthel scale
Glasgow outcome scale
strokecenter.org list of stroke assessment scales (external link)
References
Rehabilitation medicine
Medical scales
| 0.760677 | 0.98475 | 0.749077 |
The Institutes for the Achievement of Human Potential
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The Institutes for The Achievement of Human Potential (IAHP), founded in 1955 by Glenn Doman and Carl Delacato, provide literature on and teaches a controversial patterning therapy, known as motor learning, which the Institutes promote as improving the "neurologic organization" of "brain injured" and mentally impaired children through a variety of programs, including diet and exercise. The Institutes also provides extensive early-learning programs for "well" children, including programs focused on reading, mathematics, language, and physical fitness. It is headquartered in Philadelphia, with offices and programs offered in several other countries.
Pattern therapy for patients with neuromuscular disorders was first developed by neurosurgeon Temple Fay in the 1940s. Patterning has been widely criticized and multiple studies have found the therapy ineffective.
History
The Institutes for the Achievement of Human Potential (IAHP, also known as "The Institutes") was founded in 1955. It practices pattern therapy, which was developed by Doman and educational psychologist Carl Delacato. Pattern therapy drew upon the ideas and work of ideas of neurophysiologist Temple Fay, former head of the Department of Neurosurgery at Temple University School of Medicine and president of the Philadelphia Neurological Society.
In 1960, Doman and Delacato published an article in the Journal of the American Medical Association (JAMA) detailing pattern therapy. The methodology of their study was later criticized.
Philosophy
The philosophy of the Institutes consists of several interrelated beliefs: that every child has genius potential, stimulation is the key to unlocking a child's potential, teaching should commence at birth, the younger the child, the easier the learning process, children naturally love to learn, parents are their child's best teacher, teaching and learning should be joyous and teaching and learning should never involve testing. This philosophy follows very closely to the Japanese Suzuki method for violin, which is also taught at the institute in addition to the Japanese language itself. The Institutes consider brain damage, intellectual impairment, "mental deficiency", cerebral palsy, epilepsy, autism, athetosis, attention deficit hyperactivity disorder, "developmental delay", and Down syndrome as conditions encompassing "brain injury", the term favored by IAHP.
Much of the work at The Institutes follows from Dr. Temple Fay who believed in recapitulation theory, which posits that the infant brain evolves through chronological stages of development similar to first a fish, a reptile, a mammal and finally a human. This theory can be encapsulated as "ontogeny recapitulates phylogeny". Recapitulation theory has been largely discredited in biology.
According to a 2007 WPVI-TV report, IAHP uses the word "hurt" to describe the children they see "with all kinds of brain injuries and conditions, including cerebral palsy, mental retardation, epilepsy, Down's syndrome, attention deficit hyperactivity disorder, and autism". Glenn Doman described his own personal philosophy for treating patients as stemming from his WWII veteran officer motto: "Leave no injured behind."
Programs
Programs for brain-injured children
IAHP's program begins with a five-day seminar for the parents of "brain injured" children, because the program is carried out by parents at their homes. Following the seminar, IAHP conducts an initial evaluation of the child.
The program described in the 1960 JAMA paper (Doman, et al.) for "brain-injured" children included:
Patterning – manipulation of limbs and head in a rhythmic fashion
Crawling – forward bodily movement with the abdomen in contact with the floor
Creeping – forward bodily movement with the abdomen raised from the floor
Receptive stimulation – visual, tactile and auditory stimulation
Expressive activities – e.g. picking up objects
Masking – breathing into a rebreathing mask to increase the amount of carbon dioxide inhaled, which is purported to increase cerebral blood flow
Brachiation – swinging from a bar or vertical ladder
Gravity/Antigravity activities – rolling, somersaulting and hanging upside down.
The IAHP holds that brain injury at a given level of neurological development prevents or slows further progress.
Other therapies utilized by IAHP include eye exercises for children who have an eye that converges more than the other when looking at an object in the distance and those who have one eye that diverges more than the other when an object is moved slowly toward the bridge of the nose. IAHP also recommends stimulating the eyes of children with amblyopia by flashing a light on and off. For children with poor hearing, IAHP recommends auditory stimulation with loud noises, which may be pre-recorded. Brain-injured children may also be taught to identify by touch alone various objects placed in a bag.
IAHP recommends dietary restrictions, including reduced fluid intake for brain-injured children in an attempt to prevent "the possible overaccumulation of cerebrospinal fluid". Alongside fluid restriction, IAHP recommends a diet low in salt, sweets, and other "thirst provoking" foods.
Scientific evaluation and criticism
The Institutes model of childhood development has been criticized in the scientific community.
American Academy of Pediatrics position statement
According to the American Academy of Pediatrics, patterning treatment is based on an oversimplified theory of brain development and its effectiveness is not supported by evidence-based medicine, making its use unwarranted. The American Academy of Pediatrics Committee on Children With Disabilities issued warnings regarding patterning, one of the IAHP's therapies for brain injured children, as early as 1968 and repeated in 1982. Their latest cautionary policy statement was in 1999, which was reaffirmed in 2010 states:
This treatment is based on an outmoded and oversimplified theory of brain development. Current information does not support the claims of proponents that this treatment is efficacious, and its use continues to be unwarranted.... [T]he demands and expectations placed on families are so great that in some cases their financial resources may be depleted substantially and parental and sibling relationships could be stressed.
Others
In addition to the American Academy of Pediatrics, a number of other organizations have issued cautionary statements about claims for efficacy of this therapy. These include the executive committee of the American Academy for Cerebral Palsy, the United Cerebral Palsy Association of Texas, the Canadian Association for Retarded Children, the executive board of the American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation.
Hornby et al. call R.A. Cummins 1988 book The Neurologically Impaired-child: Doman-Delacato Techniques Reappraised (Croom Helm, ), "The most comprehensive analysis of the rationale and effectiveness of the Doman-Delacato programme to date" and state Cummins uses neuroanatomy and neurophysiology to demonstrate that there is no sound scientific basis for the techniques used by the IAHP and concludes any benefit is likely due to increased activity and attention. Hornby et al. conclude, "It is now clear that the only results supporting the effectiveness of the programme come from a handful of early, poorly controlled studies." Kavale and Mostert and others also identified serious problems with the early research on the IAHP program. An analysis of higher quality studies found that students not receiving the treatment had better outcomes than those who were treated by the IAHP.
A 2013 study found the claims of superior results of treatment by the IAHP were not substantiated.
A 2006 retrospective study of 21 children by the IAHP and others of children with cortical visual impairment found significant improvement after use of the program the study had no control group.
Doctors Martha Farrell Erickson and Karen Marie Kurz-Riemer wrote that IAHP "capitalized on the desires of members of the 'baby boom' generation to maximize their children's intellectual potential" and "encouraged parents to push their infants to develop maximum brain power". But most contemporary child development experts "described many aspects of the program as useless and perhaps even harmful". Kathleen Quill concluded that "professionals" have nothing to learn from pattern therapy. Pavone and Ruggieri have written that pattern therapy does not have an important role in treatment. Neurologist Steven Novella has characterized pattern therapy as being based on a discarded theory and a "false cure". He also wrote that IAHP's unsubstantiated claims can cause both financial and emotional damage. While detailing criticism of pattern therapy, Robards also wrote that the therapy caused pediatricians and therapists to recognize that early intervention programs are necessary.
The American Academy of Pediatrics and other organizations have criticized the IAHP's claims of effectiveness, theoretical basis and the demands placed on parents by IAHP programs. Early studies originating from IAHP appeared to show some value of their program but were later criticized as significantly flawed. Kenneth Kavale and Mark Mostert have written that later studies they believe to have better design and more objectivity have shown pattern therapy "to be practically without merit".
In their book Controversial Issues in Special Education, Garry Hornby, Jean Howard and Mary Atkinson state the program also includes "gagging" in which the child breathes into a plastic bag until gasping for breath. This is based on the belief that it will cause maximum use of the lungs and thus maximize oxygen circulation to the brain. The book concludes that pattern therapy is ineffective and potentially damaging to the functioning of families.
Attitude to scientific evaluation
In the 1960s, IAHP published literature that appeared to demonstrate the effectiveness of the program. However, they subsequently instructed parents of children in their program not to take part in any independent studies designed to evaluate the program's effectiveness. The IAHP withdrew its agreement to participate in a "carefully designed study supported by federal and private agencies" when the study was in its final planning stages. According to Herman Spitz, "The IAHP no longer appears to be interested in a scientific evaluation of their techniques; they have grown large, wealthy, and independent, and their staff is satisfied to provide case histories and propaganda tracts in support of their claims." Terrence M. Hines then stated that they "have shown very little interest in providing empirical support for their methods".
References
Further reading
External links
1955 establishments in Pennsylvania
Alternative therapies for developmental and learning disabilities
Applied learning
Brain
Educational institutions established in 1955
Medical controversies
Non-profit organizations based in Pennsylvania
Organizations for children with health issues
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Physical health in schizophrenia
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People with schizophrenia are at a higher than average risk of physical ill health, and earlier death than the general population. The fatal conditions include cardiovascular, respiratory and metabolic disorders.
Although death by suicide in schizophrenia has received much needed attention, and is the leading cause of death among males, death from cardiovascular disease is more common in females, accounting for up to 75 percent of deaths. The causes of physical health problems include factors associated with mental illness and its treatment, poverty, poor housing, higher rates of smoking, poor diet and lack of exercise.
Dynamics
Despite the high rates of physical health problems, mental health service users report that health care workers overlook their physical health needs. Service users would like mental health practitioners to do more for their physical health. Rethink interviewed 2,998 mental health service users, over half of whom lived with a diagnosed severe mental illness. Nearly one third said regular physical health checks were in their top three priorities for improving services. Mental health practitioners may feel unable to provide physical health input. Also there may be a feeling that people with mental health problems will not be interested in physical health education and support. In fact, much health promotion is simple and well received by service users. One review showed that people with schizophrenia benefited from a variety of behavioural interventions and achieved weight loss and lifestyle change.
Schizophrenia also affects the attendance to cancer screening which is seen as one of the factors leading to shorter life expectancy. For example, women with schizophrenia are half as likely to attend breast cancer screening compared to the general population.
Another study found little evidence to support one intervention over another, but argued that moderately strenuous exercise was important.
Health policy
Many guidelines reflect the need to incorporate physical health care into mental health provision, including NICE in the UK. In primary care, the prodigy website provides practical and accessible advice.
However, a review of international guidelines for physical wellbeing in SMI has found that recommendations are variable. UK guidelines failed to address the specifics of physical health monitoring and lifestyle intervention, while United States guidelines were more descriptive. Field studies suggested that all guidelines were inadequately implemented in practice.
The DoH in the UK has recommended wide-ranging action to enable the general population to choose healthier lifestyles in the Choosing Health white paper.
In the UK the National Health Service (NHS) is deeply split along physical/mental lines. These services tend to treat parts of people separately.
The commissioning framework to support the physical health needs of people with severe mental illness recommends a holistic approach with interagency collaboration.
Medication
The current medical view is that all people with schizophrenia must take medications for the disorder. These antipsychotic medications have adverse effects such as weight gain and induce feelings of fatigue that inhibit physical activity. The request for the people with schizophrenia to exercise for cardiovascular health then take medications (originally named "major tranquilizers") that inhibit activity is a double bind.
See also
Schizophrenia and smoking
References
Schizophrenia
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Acrodynia
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Acrodynia is a medical condition which occurs due to mercury poisoning. The condition of pain and dusky pink discoloration in the hands and feet is due to exposure or ingesting of mercury. It was known as pink disease (due to these symptoms) before it was accepted that it was just mercury poisoning.
The word acrodynia is derived from the , which means end or extremity, and , which means pain. As such, it might be (erroneously) used to indicate that a patient has pain in the hands or feet. The condition is known by various other names including hydrargyria, mercurialism, erythredema, erythredema polyneuropathy, Bilderbeck's, Selter's, Swift's and Swift-Feer disease.
Symptoms and signs
Besides peripheral neuropathy (presenting as paresthesia or itching, burning or pain) and discoloration, swelling (edema) and desquamation may occur. Since mercury blocks the degradation pathway of catecholamines, epinephrine excess causes profuse sweating (diaphora), tachycardia, salivation and elevated blood pressure. Mercury is suggested to inactivate S-adenosyl-methionine, which is necessary for catecholamine catabolism by catechol-o-methyl transferase. Affected children may show red cheeks and nose, red (erythematous) lips, loss of hair, teeth, and nails, transient rashes, hypotonia and photophobia. Other symptoms may include kidney dysfunction (e.g. Fanconi syndrome) or neuropsychiatric symptoms (emotional lability, memory impairment, insomnia).
Thus, the clinical presentation may resemble pheochromocytoma or Kawasaki disease.
There is some evidence that the same mercury poisoning may predispose to Young's syndrome (men with bronchiectasis and low sperm count).
Causes
Mercury compounds like calomel were historically used for various medical purposes: as laxatives, diuretics, antiseptics or antimicrobial drugs for syphilis, typhus and yellow fever.
Teething powders were a widespread source of mercury poisoning until the recognition of mercury toxicity in the 1940s.
However, mercury poisoning and acrodynia still exist today. Modern sources of mercury intoxication include broken thermometers.
Diagnosis
Removal of the inciting agent is the goal of treatment. Correcting fluid and electrolyte losses and rectifying any nutritional imbalances (vitamin-rich diets, vitamin-B complex) are of utmost importance in the treatment of the disease.
The chelating agent meso 2,3-dimercaptosuccinic acid has been shown to be the preferred treatment modality. It can almost completely prevent methylmercury uptake by erythrocytes and hepatocytes. In the past, dimercaprol (British antilewisite; 2,3-dimer-capto-l-propanol) and D-penicillamine were the most popular treatment modalities. Disodium edetate (Versene) was also used. Neither disodium edetate nor British antilewisite has proven reliable. British antilewisite has now been shown to increase CNS levels and exacerbate toxicity. N -acetyl-penicillamine has been successfully given to patients with mercury-induced neuropathies and chronic toxicity, although it is not approved for such uses. It has a less favorable adverse effect profile than meso 2,3-dimercaptosuccinic acid.
Hemodialysis with and without the addition of L-cysteine as a chelating agent has been used in some patients experiencing acute kidney injury from mercury toxicity. Peritoneal dialysis and plasma exchange also may be of benefit.
Tolazoline (Priscoline) has been shown to offer symptomatic relief from sympathetic overactivity. Antibiotics are necessary when massive hyperhidrosis, which may rapidly lead to miliaria rubra, is present. This can easily progress to bacterial secondary infection with a tendency for ulcerating pyoderma.
References
Occupational diseases
Toxicology
Pediatrics
| 0.761376 | 0.98334 | 0.748692 |
Therapy speak
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Therapy speak is the incorrect use of jargon from psychology, especially jargon related to psychotherapy and mental health. It tends to be linguistically prescriptive and formal in tone.
Therapy speak is related to psychobabble and buzzwords. It is vulnerable to miscommunication and relationship damage as a result of the speaker not fully understanding the terms they are using, as well as using the words in a weaponized or abusive manner. Therapy speak is not generally used by therapists during psychotherapy sessions.
Motivation
Although the use of therapy speak may be unconscious, a variety of different motivations have been identified in different situations.
People use therapy speak because it makes themselves or their emotions sound more important or superior. In this sense, the use of therapy speak may be no different from academese, which is jargon needlessly used by university professors and other academics to make themselves sound educated. This can come across as the speaker being condescending and unkind. Therapy speak may be used in other ways to claim social status, e.g., by engaging in conspicuous consumption under the guise of self-care.
The motivation may be to win an argument, or to prevent people from questioning why they have issued a demand.
Therapy speak is sometimes used by "deeply insecure" people to mask their discomfort, avoid conflict, or to create distance in a relationship. Instead of saying something clear, like "I don't want to be friends any longer", they may use therapy speak and instead say something vague like "I don't have the emotional capacity for a relationship". It may be used as a defence mechanism to put emotional distance between them, their feelings, and the situation. They may be hoping that using therapy speak will elicit more sympathy, or at least tamp down overt criticism of themselves. Because it can distance the speaker from culpability for what they say and do, it has been compared to the jargon used in businesses in human resource policies and similarly formal corporate communications to employees.
People also use therapy speak to cover up being controlling. Rather than using the language of psychology to describe oneself, the speaker uses it to judge others.
Another motivation for using therapy speak is to get more support. Some people may find that their needs are more likely to be met when they use therapy speak (e.g., "I was traumatized by the traffic jam this morning") than if they use ordinary language (e.g., "I felt stressed because the traffic made me late").
Among people who are dating, using therapy speak may be an attempt to signal that the speaker is emotionally mature or financially stable. Talking about psychotherapy during a first date may increase the likelihood of a second date.
Employers may use therapy speak as well as psychology-based activities, such educational sessions about burnout and stress management, to address some complaints from employees. This may be considered psychwashing (whitewashing a bad situation through psychology), as it redirects attention away from the problems caused by the company (e.g., poor management, overworked employees, low pay) towards problems with the individual (e.g., feeling stressed because the work is pointless and poorly paid).
Effects
Therapy speak can be associated with controlling behavior. It can be used as a weapon to shame people or to pathologize them by declaring the other person's behavior (e.g., accidentally hurting the other person's feelings) to be a mental illness, as well as a way to excuse or minimize the speaker's choices, for example, by blaming a conscious behavior like ghosting on their attachment style, rather than working to change the behavior.
Like other forms of pop psychology, therapy speak can result in miscommunication. When people use the same word to mean different things, they may have difficulty understanding each other. For example, someone might talk about trauma bonding, thinking that it's the emotional bond between survivors of a shared experience; the actual meaning is the emotional attachment of abuse victims to their abusers. Using the word to refer to a relationship between abuse survivors will confuse people who believe it refers to an abuser–victim relationship, and vice versa. Therapists may deal with this by asking the speaker to define the word or explain it in more detail. It also impairs communication by substituting a superficial judgement for clear communication.
Therapy speak can prevent the person from clearly and correctly understanding their situation or relationship. Labeling a person or situation with psychology jargon may stop people from exploring any of the nuances or complexities. For example, someone may say that a person is toxic, when it would be more productive to understand how they have been hurt by this person, or even whether they have been hurt. Additionally, it may disempower people and reduce their psychological resilience by causing them to believe that minor or ordinary unpleasant feelings are symptoms of psychological disorders. This can make managing the situation seem more difficult and can produce an identity around being mentally ill.
Mislabeling a situation (e.g., calling it trauma, when what the person is experiencing may be better described as grief, feeling overwhelmed, being upset, or experiencing a stress response) may prevent the person from finding effective coping mechanisms. The lack of nuance, and its tendency towards glibness, may make it harder for the speaker to authentically interrogate and understand their own responses.
According to psychotherapist Esther Perel, "[in therapy speech], there is such an emphasis on the ‘self-care’ aspect of it that is actually making us more isolated and more alone, because the focus is just on the self". Therapists find that using therapy speak can prevent people from being open and vulnerable with each other. It may be used in an attempt to define the other person's lived experiences. It is frequently used in ways that elevate a one-sided view of a relationship or situation.
When used to exaggerate – to describe an everyday harm as more serious trauma, conflating a normal level of tidiness with obsessive–compulsive disorder, mislabeling conflict as abuse – therapy speak can harm people who have serious mental conditions by taking away the language used to describe their more extreme situations. However, therapy speak also has the effect of normalizing and de-stigmatizing mental health problems.
Therapy speak is often used to confess failings.
Misuse of specific words may have specific effects. For example, overuse of trauma can make people with post-traumatic stress disorder feel like their life and identity is centered around their trauma. Using narcissism to complain about ordinary self-interest or inconsiderateness can harm communication and discourage other people from seeking fair arrangements, for fear that asking for fairness will be called narcissistic behavior. Saying "I was triggered" can minimize the interior experience of fear or anger.
More generally, when the jargon of psychology becomes commonplace, the words may lose their meanings, through a process called semantic bleaching.
Examples
Some words encountered in psychotherapy are commonly misused.
Trauma Many psychotherapists consider the term "trauma" to be overused to describe "anything bad", in the words of George Bonanno, psychological trauma is often defined to begin with a horrific "violent or life-threatening event that is outside the range of normal experience", such as rape, a natural disaster, or a mass shooting. Early symptoms may include shock and denial; later symptoms, for those who develop post-traumatic stress disorder, may include unpredictable labile mood (e.g., a normal comment provokes an obviously abnormal feeling), intense nightmares or flashbacks (feeling like the traumatic event is happening again), and other debilitating symptoms. However, other clinicians will argue that another form of trauma isn't yet included in the DSM, caused by experiences that may not be explicitly violent, but still mirror the effects of more "severe" trauma and affects people deeply.
Trigger The term "trigger" is often used to say that the person is upset, or that a behavior caused the person to feel bad. However, a trauma trigger in clinical settings describes something harmless (e.g., the sound of a motorcycle) that is mentally tied for that individual to a previous terrible event (e.g., witnessing gun violence).
Gaslighting Declared to be the 2022 word of the year by Merriam-Webster, gaslighting is often used to describe ordinary disagreement or lying and people who refuse to believe that they have caused any harm. In its original meaning, gaslighting, which is also called coercive control, is used to describe a form of long-term psychological manipulation and emotional abuse by a close, trusted person (such as a romantic partner, family member, or close friend), that increases the abuser's power and control by making the other person doubt their perception of reality.
Narcissism The word "narcissism", increasingly used in common speech to imply narcissistic personality disorder, may be used casually to imply that people with ordinary or individual acts of self-centeredness, selfishness, rudeness, or self-importance have a serious disorder. However, narcissistic personality disorder is instead a pattern of long-term behavior that takes self-involvement to an unhealthy extreme, involving an unrealistic sense of superiority (grandiosity), the need for others to admire them, and a lack of empathy.
Depressed Used for many unpleasant experiences, including temporary sadness, experiencing disappointment, and feeling discouraged, clinical depression is an extreme level of sadness that lasts for weeks (or longer) and that interferes with activities of daily life (such as eating, sleeping, and maintaining basic hygiene standards).
Boundaries "Setting a boundary" is often misused to mean creating a family estrangement if the speaker's wishes are not fulfilled by others, but in psychotherapy, a boundary is carefully considered choice that is meant to preserve relationships. A boundary is about the actions taken by the person who set the boundary. For example, a person might decide that if someone asks about a painful situation, they will say "I don't feel like talking about that right now", and then repeat that statement as many times as necessary. Rather than hiding from other people or trying to control what others do, a proper boundary supports interaction and takes the other person's needs into account.
Codependency "Codependency" may be sometimes used to say that the speaker believes that a person is too invested in a relationship; however, codependency is instead an unhealthy relationship that enables destructive behavior.
Self-care Meant to refer to ordinary care for the body, such as by getting enough sleep, it is often used to mean pampering, such as through an expensive day at a spa.
History
The phenomenon of jargon from psychology appearing in everyday language predates even Sigmund Freud, who popularized concepts such as repression and denial more than a century ago. For example, the word triggered has become more popular since the mid-20th century. It became trendy on social media platforms during the 2010s, and can be found in dating apps.
The popularity of therapy speak correlates with the decline of institutionalized religion, which provides opportunities to make sense of difficult experiences, and the increased use of mental health services, especially during the COVID-19 pandemic. It is also connected to the rise of therapy culture, which is a belief that everyone benefits from undergoing psychotherapy and that psychotherapy can solve people's problems.
Therapy speak has also been used in academic publications.
The act of claiming that another person is mentally ill without much evidence, or being an "armchair psychologist", is also not a new social or relationship phenomenon.
The trend towards using therapy speak online may be due to loss of nuance and the sound bite nature of social media. A brief, impersonal example of how to break off a friendship might be misinterpreted on social media as a correct, humane, and emphathetic way to treat other people.
Related therapeutic problems
In addition to the jargon of psychology appearing in everyday speech, there are related problems, such as expecting everyone to behave like a therapist. This can manifest in the form of expecting emotional validation (a therapeutic technique) from everyone, which, when accepted within a larger group, can slide into overvaluing people's emotional experiences.
See also
Curse of knowledge – using technical jargon correctly, but not being understood because the audience does not know the same jargon
References
External links
What Happens When Therapy-Speak Creeps Into a Relationship at Psychology Today
Buzzword
Social sciences terminology
Popular psychology
Psychological manipulation
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Psychological injury
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A psychological injury is the psychological or psychiatric consequence of a traumatic event or physical injury. Such an injury might result from events such as abusive behavior, whistleblower retaliation, bullying, kidnapping, rape, motor vehicular collision or other negligent action. It may cause impairments, disorders, and disabilities perhaps as an exacerbation of a pre-existing condition (e.g., Dalby, Maclean, & Nesca, 2022; Drogin, Dattilio, Sadoff, & Gutheil, 2011; Duckworth, Iezzi, & O'Donohue, 2008; Kane & Dvoskin, 2011; Koch, Douglas, Nicholls, & O'Neil, 2006; Schultz & Gatchel, 2009; Young, 2010, 2011; Young, Kane, & Nicholson, 2006, 2007).
Psychological injury is considered a mental harm, suffering, damage, impairment, or dysfunction caused to a person as a direct result of some action or failure to act by some individual. The psychological injury must reach a degree of disturbance of the pre-existing psychological/ psychiatric state such that it interferes in some significant way with the individual's ability to function. If so, an individual may be able to sue for compensation/ damages.
Typically, a psychological injury may involve posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), a concussion, chronic pain, or a disorder that involves mood or emotions (such as depression, anxiety, fear, or phobia, and adjustment disorder). These disorders may manifest separately or in combination (co-morbidity). If the symptoms and effects persist, the injured person may become a complainant or plaintiff who initiates legal action aimed at obtaining compensation against whoever is considered responsible for the injury.
Diagnosis and treatment
Psychologists and psychiatrists are those professionals typically qualified by their regulating or licensing bodies or boards to diagnose and treat psychological injuries. Psychologists are trained in the study of behavior and its assessment, diagnosis, and treatment. Many psychological tests are limited in their use to psychologists, as psychiatrists are unlikely receive substantial training in test administration and interpretation. However, being medical professionals, psychiatrists have skills and a knowledge base not typically available to psychologists. The Diagnostic and Statistical Manual of Mental Disorders—now in its fourth edition (DSM-IV-TR, American Psychiatric Association, 2000)—will soon be updated by a fifth edition slated for publication in 2013 (see Young and First, 2010, for a critique). This Manual is prepared under the aegis of the American Psychiatric Association, but psychologists contribute to this process by participating in its working groups.
Rehabilitation and other clinical psychologists—such as trauma psychologists—may be in professional contact with injured survivors at the onset injury, shortly thereafter, and throughout the course of recovery, such that these professionals, too, need to know about the legal ramifications of the field. They may employ cognitive behavioral approaches to help their patients deal with any physical injuries, pain experience, PTSD, mood, and effects of their brain injuries (Young, 2008b). They may assist the families of the injured, including spouses and children. They typically adopt a systems approach, working as part of rehabilitative teams. Their hardest cases occur when there is a death in the family as a result of the event for which legal action is involved and therapy is needed. These clinical, rehabilitation, and trauma psychologists refer to treatment guidelines in preparing their treatment plans, and attempt to keep their practices evidence-based when feasible.
Major psychological injuries
Chronic pain
Chronic pain is another controversial psychological condition, labeled in the DSM-IV-TR as Pain Disorder Associated with Psychological Factors (with or without a Medical Condition). The "biopsychosocial approach" recognizes the influence of psychological factors (e.g., stress) on pain. It was once thought that chronic pain could be the result of a "pain-prone personality" or that it is "all in the head." Contemporary research tends to dismiss such conceptualizations, but they continue persist and cause distress to patients whose pain is not recognized as real. Psychologists have an important role to play in helping patients in pain by providing appropriate education and treatment (for example, about catastrophizing or fearing the worst), and by using standard cognitive and behavioral techniques (such as breathing exercises, muscle relaxation, and dealing with cognitive distortions) (see Gatchel, Peng, Fuchs, Peters, and Turk, 2007; Schatman and Gatchel, 2010).
Traumatic brain injury (TBI)
TBI refers to mild to severe pathophysiological effects in the brain and central nervous system due to strong impacts, such as severe blows to the head and penetrating wounds that might take place in accidents and other events at claim. Neuropsychological deficits associated with TBI include those relating to memory, concentration, attention, processing speed, reasoning, problem solving, planning, and inhibitory control. When these effects persist, other psychological difficulties might arise, even in mild cases (such as concussions). However, the underlying reason for the perpetuation of the symptoms beyond the expected time frame might be due to associated factors, such as poor sleep, fatigue, pain, headaches, and distress. Psychologists can help patients with TBI by guiding them in cognitive remediation and dealing with family. When the effects are serious and even devastating, the degree of care from the team may be intensive, covering multiple aspects of daily living (see Ruff and Richards, 2009).
People of both sexes and all types of backgrounds, races, ages, and disability status are injured physically and psychologically in events at claim and in other situations. However, the research does not always consider these differences, and often the diagnostic manuals, psychological tests, and therapeutic protocols in use in the area also lack differentiation along these lines.
Disability and return to work
When psychological injuries compromise daily activities, psychologists need to address the degree of disability (see Schultz, 2009; Schultz & Rogers, 2011). Patients express symptoms that might be accurately diagnosed as PTSD, Pain Disorder, and/or TBI. However, the critical issue is the degree of impairment, limitation, and participation restriction in daily activities in which patients would normally participate at work, at home, in childcare, and in schooling. When the patient cannot undertake the functions involved in these important roles, the psychologist or other mental health professional may conclude that a disability is present, but this cannot be ascertained by the mere presence of a diagnosis of one sort or another. Rather, the psychologist must demonstrate that the person is disabled from the essential duties, tasks, or activities of the role at issue. For example, a forefinger injury leading to chronic pain might mean relatively little to an investment banker—as long as medications control it and other areas of functioning are not greatly affected—but might be devastating to a violinist. Psychologists may refer to the American Medical Association's Guides to the Evaluation of Permanent Impairment (Rondinelli, Genovese, Katz, Mayer, Müller, Ranavaya, & Brigham, 2008) in arriving at disability determinations, which addresses mental health, neuropsychological, and pain issues. However, like the DSM-IV-TR, this compendium is sometimes questioned for its scientific validity and usefulness.
Tort actions and other civil actions are often based on serious, permanent and important psychological injuries that create disabilities of a substantial nature in other areas, such as leisure activities, home care, and family life. Often, psychologists in court lock horns over the degree to which the event at claim and its psychological effects have created serious and potentially permanent psychological disabilities—in part, because there is no one test that can measure "disability," per se.
Treating psychologists try to help clients return to work (RTW) or to their other functional roles and activities of daily living (ADLs). Clients are expected to adhere to treatment regimens, or be compliant with treatment recommendations. Partly, this serves to mitigate their losses, or attempt to return to their pre-event physical and psychological condition. When they reach or are progressing to their maximum medical recovery (physical and psychological/ psychiatric recovery), RTW might be attempted on a modified, part-time, or accommodated basis, and treatment might continue to help full re-integration into the workforce or other daily roles, and to maintain gains and avoid deterioration. Or, clients might be sent for training or education, based on their transferable skills residual to the event at claim and its effects. For those who do not make full recovery and remain disabled because of their permanent barriers to recovery, the goals of rehabilitation include optimizing adjustment, quality of life (QOL), residual functionality, and wellness.
Psychological testing
Psychologists need to use the most appropriate tests available for detecting the person(s) responsible for the psychological injury. In addition, psychologists need to be able to arrive at scientifically informed conclusions in their evaluations that will withstand the rigors of scrutiny by psychologists on the opposing side and of cross-examination in court.
In terms of their education and training, psychologists need to be able to address the full array of areas under discussion, especially in forensic, rehabilitation, and trauma areas. They must become experts in assessment and testing, especially regarding (a) personality tests (e.g., the MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Butcher, Graham, Ben-Porath, Tellegen, Dahlstrom, & Kaemmer, 2001; and the revision the MMPI-2 RF; Ben-Porath & Tellegen, 2008; as well as the PAI; Morey, 2007), and their embedded validity scales, such as the F family of scales in the MMPI tests, and (b) stand-alone symptom validity tests (e.g., the TOMM; Tombaugh, 1996; WMT; Green, 2005; SIRS; Rogers, Bagby, & Dickens, 1992; and the revision SIRS-2; Rogers, Sewell, & Gillard, 2010). The key factors in the development of tests that are acceptable to psychologists and to court is that the tests should have acceptable psychometric properties, such as reliability and validity. Also, such tests must be standardized by using populations that make sense for the area of psychological injuries, such as accident survivors experiencing pain and other trauma victims.
See also
Causality
Forensic psychiatry
Forensic psychology
Evidence (Law)
Expert witness
Malingering
Chronic pain syndrome
Personal injury
Psychological Injury and Law
Rehabilitation
Tort
Traumatic brain injury complications
References
External links
American Bar Association – Tort Trial and Insurance Practice Section
APA Division 5: Evaluation, Measurement, & Statistics
APA Division 22: Rehabilitation Psychology
APA Division 41: American Psychology – Law Society
APA Division 56: Division of Trauma Psychology
Americans with Disabilities Act
Canadians with Disabilities Act
International Society for Traumatic Stress Studies
Forensic psychology
United States labor law
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Community mobilization
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Community mobilization is an attempt to bring both human and non-human resources together to undertake developmental activities in order to achieve sustainable development.
Process
Community mobilization is a process through which action is stimulated by a community itself, or by others, that is planned, carried out, and evaluated by a community's individuals, groups, and organizations on a participatory and sustained basis to improve the health, hygiene and education levels so as to enhance the overall standard of living in the community.
A group of people have transcended their differences to meet on equal terms in order to facilitate a participatory decision-making process. In other words, it can be viewed as a process which begins a dialogue among members of the community to determine who, what, and how issues are decided, and also to provide an avenue for everyone to participate in decisions that affect their lives.
Requirements
Community mobilization needs many analytical and supportive resources which are internal (inside the community) and external (outside the community) as well. Resources include:
Leadership
Organizational capacity
Communications channels
Assessments
Problem solving
Resource mobilization
Administrative and operational management
Strategies
The Centre for Disease Control envisions that strong healthcare initiatives will be readily owned by a community if the leaders ("grass tops"), the citizens ("grass roots"), and youth are fully engaged in mobilizing the community, educating stakeholders, and implementing evidence-based interventions.
To this respect, 14 strategies guided by best practice have been reported (Huberman 2014):
1. Secure strong leadership
2. Establish a formal structure
3. Engage diverse organizations, community leaders, and residents
4. Ensure authentic participation and shared decision making
5.ensure authentic and productive roles for young people
6. Develop a shared vision
7. Conduct a needs assessment
8. Create a strategic plan
9. Implement mutually reinforcing strategies
10. Create a fundraising strategy
11. Establish effective channels for internal communication
12. Educate the community
13. Conduct process and outcome evaluations
14. Evaluate the community mobilization effort separately
Implications
"Community mobilization" is a frequently used term in developmental sector. Recently, community mobilization has been proved to be a valuable and effective concept which has various implications in dealing with basic problems like health and hygiene, population, pollution and gender bias.
References
Community organizing
Community
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Equifinality
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Equifinality is the principle that in open systems a given end state can be reached by many potential means. The term and concept is due to the German Hans Driesch, the developmental biologist, later applied by the Austrian Ludwig von Bertalanffy, the founder of general systems theory, and by William T. Powers, the founder of perceptual control theory. Driesch and von Bertalanffy prefer this term, in contrast to "goal", in describing complex systems' similar or convergent behavior. Powers simply emphasised the flexibility of response, since it emphasizes that the same end state may be achieved via many different paths or trajectories.
In closed systems, a direct cause-and-effect relationship exists between the initial condition and the final state of the system: When a computer's 'on' switch is pushed, the system powers up. Open systems (such as biological and social systems), however, operate quite differently. The idea of equifinality suggests that similar results may be achieved with different initial conditions and in many different ways. This phenomenon has also been referred to as isotelesis (from Greek ἴσος isos "equal" and τέλεσις telesis: "the intelligent direction of effort toward the achievement of an end") when in games involving superrationality.
Overview
In business, equifinality implies that firms may establish similar competitive advantages based on substantially different competencies.
In psychology, equifinality refers to how different early experiences in life (e.g., parental divorce, physical abuse, parental substance abuse) can lead to similar outcomes (e.g., childhood depression). In other words, there are many different early experiences that can lead to the same psychological disorder.
In archaeology, equifinality refers to how different historical processes may lead to a similar outcome or social formation. For example, the development of agriculture or the bow and arrow occurred independently in many different areas of the world, yet for different reasons and through different historical trajectories. This highlights that generalizations based on cross-cultural comparisons cannot be made uncritically.
In Earth and environmental Sciences, two general types of equifinality are distinguished: process equifinality (concerned with real-world open systems) and model equifinality (concerned with conceptual open systems). For example, process equifinality in geomorphology indicates that similar landforms might arise as a result of quite different sets of processes. Model equifinality refers to a condition where distinct configurations of model components (e.g. distinct model parameter values) can lead to similar or equally acceptable simulations (or representations of the real-world process of interest). This similarity or equal acceptability is conditional on the objective functions and criteria of acceptability defined by the modeler. While model equifinality has various facets, model parameter and structural equifinality are mostly known and focused in modeling studies. Equifinality (particularly parameter equifinality) and Monte Carlo experiments are the foundation of the GLUE method that was the first generalised method for uncertainty assessment in hydrological modeling. GLUE is now widely used within and beyond environmental modeling.
See also
GLUE – Generalized Likelihood Uncertainty Estimation (when modeling environmental systems there are many different model structures and parameter sets that may be behavioural or acceptable in reproducing the behaviour of that system)
TMTOWTDI – Computer programming maxim: "there is more than one way to do it"
Underdetermination
Consilience
Convergent evolution
Teleonomy
Degeneracy (biology)
Kruskal's principle
Multicollinearity
References
Publications
Bertalanffy, Ludwig von, General Systems Theory, 1968
Beven, K.J. and Binley, A.M., 1992. The future of distributed models: model calibration and uncertainty prediction, Hydrological Processes, 6, pp. 279–298.
Beven, K.J. and Freer, J., 2001a. Equifinality, data assimilation, and uncertainty estimation in mechanistic modelling of complex environmental systems, Journal of Hydrology, 249, 11–29.
Croft, Gary W., Glossary of Systems Theory and Practice for the Applied Behavioral Sciences, Syntropy Incorporated, Freeland, WA, Prepublication Review Copy, 1996
Durkin, James E. (ed.), Living Groups: Group Psychotherapy and General System Theory, Brunner/Mazel, New York, 1981
Mash, E. J., & Wolfe, D. A. (2005). Abnormal Child Psychology (3rd edition). Wadsworth Canada. pp. 13–14.
Weisbord, Marvin R., Productive Workplaces: Organizing and Managing for Dignity, Meaning, and Community, Jossey-Bass Publishers, San Francisco, 1987
Tang, J.Y. and Zhuang, Q. (2008). Equifinality in parameterization of process-based biogeochemistry models: A significant uncertainty source to the estimation of regional carbon dynamics, J. Geophys. Res., 113, G04010.
Systems theory
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Synectics
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Synectics is a problem solving methodology that stimulates thought processes of which the subject may be unaware. This method was developed by George M. Prince (1918–2009) and William J.J. Gordon, originating in the Arthur D. Little Invention Design Unit in the 1950s.
According to Gordon, Synectics research has three main assumptions:
the creative process can be described and taught
invention processes in arts and sciences are analogous and are driven by the same "psychic" processes
individual and group creativity are analogous
History
The process was derived from tape-recording (initially audio, later video) meetings, analysis of the results, and experiments with alternative ways of dealing with the obstacles to success in the meeting. "Success" was defined as getting a creative solution that the group was committed to implement.
The name Synectics comes from Greek and means "the joining together of different and apparently irrelevant elements."
Gordon and Prince named both their practice and their new company Synectics, which can cause confusion, as people not part of the company are trained and use the practice. While the name was trademarked, it has become a standard word for describing creative problem solving in groups.
Theory
Synectics is a way to approach creativity and problem-solving in a rational way. "Traditionally, the creative process has been considered after the fact... The Synectics study has attempted to research creative process in vivo, while it is going on."
According to Gordon, Synectics research has three main assumptions:
The creative process can be described and taught;
Invention processes in arts and sciences are analogous and are driven by the same "psychic" processes;
Individual and group creativity are analogous.
With these assumptions in mind, Synectics believes that people can be better at being creative if they understand how creativity works.
One important element in creativity is embracing the seemingly irrelevant. Emotion is emphasized over intellect and the irrational over the rational. Through understanding the emotional and irrational elements of a problem or idea, a group can be more successful at solving a problem.
Prince emphasized the importance of creative behaviour in reducing inhibitions and releasing the inherent creativity of everyone. He and his colleagues developed specific practices and meeting structures which help people to ensure that their constructive intentions are experienced positively by one another. The use of the creative behaviour tools extends the application of Synectics to many situations beyond invention sessions (particularly constructive resolution of conflict).
Gordon emphasized the importance of metaphorical process' to make the familiar strange and the strange familiar". He expressed his central principle as: "Trust things that are alien, and alienate things that are trusted." This encourages, on the one hand, fundamental problem-analysis and, on the other hand, the alienation of the original problem through the creation of analogies. It is thus possible for new and surprising solutions to emerge.
As an invention tool, Synectics invented a technique called "springboarding" for getting creative beginning ideas. For the development of beginning ideas, the method incorporates brainstorming and deepens and widens it with metaphor; it also adds an important evaluation process for Idea Development, which takes embryonic new ideas that are attractive but not yet feasible and builds them into new courses of action which have the commitment of the people who will implement them.
Synectics is more demanding of the subject than brainstorming, as the steps involved imply that the process is more complicated and requires more time and effort. The success of the Synectics methodology depends highly on the skill of a trained facilitator.
Books
The Practice of Creativity: A Manual for Dynamic Group Problem-Solving. George M. Prince, 2012, Vermont: Echo Point Books & Media, LLC, 0-9638-7848-4
The Practice of Creativity by George Prince 1970
Synectics: The Development of Creative Capacity by W. J. J. Gordon, London, Collier-MacMillan, 1961
Design Synectics: Stimulating Creativity in Design by Nicholas Roukes, Published by Davis Publications, 1988
The Innovators Handbook by Vincent Nolan 1989
Creativity Inc.: Building an Inventive Organization by Jeff Mauzy and Richard Harriman 2003
Imagine That! by Vincent Nolan and Connie Williams, Publishers Graphics, LLC, 2010
See also
List of thought processes
References
External links
George Prince website "Thoughts on Creativity"
Synecticsworld's Founders page on George M. Prince and Bill Gordon
Creativity
Problem solving
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Externalizing disorder
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Externalizing disorders (or externalising disorders) are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual's environment, which cause impairment or interference in life functioning. In contrast to individuals with internalizing disorders who internalize (keep inside) their maladaptive emotions and cognitions, such feelings and thoughts are externalized (manifested outside) in behavior in individuals with externalizing disorders. Externalizing disorders are often specifically referred to as disruptive behavior disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder) or conduct problems which occur in childhood. Externalizing disorders, however, are also manifested in adulthood. For example, alcohol- and substance-related disorders and antisocial personality disorder are adult externalizing disorders. Externalizing psychopathology is associated with antisocial behavior, which is different from and often confused for asociality.
Signs and symptoms
Externalizing disorders often involve emotion dysregulation problems and impulsivity that are manifested as antisocial behavior and aggression in opposition to authority, societal norms, and often violate the rights of others. Some examples of externalizing disorder symptoms include, often losing one's temper, excessive verbal aggression, physical aggression to people and animals, destruction of property, theft, and deliberate fire setting. As with all DSM-5 mental disorders, an individual must have functional impairment in at least one domain (e.g., academic, occupational, social relationships, or family functioning) in order to meet diagnostic criteria for an externalizing disorder. Moreover, an individual's symptoms should be atypical for their cultural and environmental context and physical medical conditions should be ruled out before an externalizing disorder diagnosis is considered. Diagnoses must be made by qualified mental health professionals. DSM-5 classifications of externalizing disorders are listed herein, however, ICD-10 can also be used to classify externalizing disorders. More specific criteria and examples of symptoms for various externalizing disorders can be found in the DSM-5.
DSM-5 classification
There are no specific criteria for "externalizing behavior" or "externalizing disorders". Thus, there is no clear classification of what constitutes an externalizing disorder in the DSM-5. Attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), antisocial personality disorder (ASPD), pyromania, kleptomania, intermittent explosive disorder (IED), and substance-related disorders are frequently referred to as externalizing disorders. Disruptive mood dysregulation disorder has also been posited as an externalizing disorder, but little research has examined and validated it to date given its recent addition to the DSM-5, and thus, it is not included further herein.
Attention-deficit/hyperactivity disorder
Inattention ADHD symptoms include: "often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities," "often has difficulty sustaining attention in tasks or play activities," "often does not seem to listen when spoken to directly," "often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace," "often has difficulty organizing tasks and activities," "often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort," "often loses things necessary for tasks or activities," "is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts)," and "is often forgetful in daily activities."
Hyperactivity and impulsivity ADHD symptoms include: "often fidgets with or taps hands or feet or squirms in seat," "often leaves seat in situations when remaining seated is expected," "often runs about or climbs in situations where it is inappropriate," "is often unable to play or engage in leisure activities quietly," "is often "on the go," acting as if "driven by a motor," "often talks excessively," "often blurts out an answer before a question has been completed," "often has difficulty waiting his or her turn," and "often interrupts or intrudes on others."
In order to meet criteria for an ADHD diagnosis, an individual must have at least six symptoms of inattention and/or hyperactivity/impulsivity, have an onset of several symptoms prior to age 12 years, have symptoms present in at least two settings, have functional impairment, and have symptoms that are not better explained by another mental disorder.
Oppositional defiant disorder
ODD symptoms include: "often loses temper," "is often touchy or easily annoyed," "is often angry and resentful," "often argues with authority figures, or for children and adolescents, with adults," "often actively defies or refuses to comply with requests from authority figures or with rules," "often deliberately annoys others," and "often blames others for his or her mistakes or misbehavior." In order to receive an ODD diagnosis, individuals must have at least four symptoms from above for at least six months (most days for youth younger than five years) with at least one individual who is not a sibling, which causes impairment in at least one setting. Rule outs for a diagnosis include symptoms occurring concurrently during an episode of another disorder.
Conduct disorder
CD symptoms include "often bullies, threatens, or intimidates others," "often initiates physical fights," "has used a weapon that can cause serious physical harm to others," "has been physically cruel to people," "has been physically cruel to animals," "has stolen while confronting a victim," "has forced someone into sexual activity," "has deliberately engaged in fire setting with the intention of causing serious damage," "has deliberately destroyed others' property (other than by fire setting)," "has broken into someone else's house, building, or car," "often lies to obtain goods or favors or to avoid obligations," "has stolen items of nontrivial value without confronting a victim," "often stays out at night despite parental prohibitions, beginning before age 13 years," "has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period," and "is often truant from school, beginning before age 13 years." In order to receive a CD diagnosis, individuals must have three of these symptoms for at least one year, at least two symptoms for at least six months, be impaired in at least one setting, and not have an antisocial personality disorder diagnosis if 18 years or older.
Antisocial personality disorder
ASPD symptoms include: "failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest," "deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure," "impulsivity or failure to plan ahead," "irritability and aggressiveness, as indicated by repeated physical fights or assaults," "reckless disregard for safety of self or others," "consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations," and "lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another." In order to meet diagnostic criteria for ASPD, an individual must have "a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years," three or more of the above symptoms, be at least age 18 years, have a conduct disorder onset before age 15 years, and not have antisocial behavior exclusively during schizophrenia or bipolar disorder.
Pyromania
Pyromania symptoms include: "deliberate and purposeful fire setting on more than one occasion," "tension or affective arousal before the act," "fascination with, interest in, curiosity about, or attraction to fire and its situational contexts," and "pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath." In order to receive a pyromania diagnosis, "the fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment." A conduct disorder diagnosis, manic episode, or antisocial personality disorder diagnosis must not better account for the fire setting in order to receive a pyromania diagnosis.
Kleptomania
Kleptomania symptoms include: "recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value," "increasing sense of tension immediately before committing the theft," and "pleasure, gratification, or relief at the time of committing the theft." In order to receive a kleptomania diagnosis, "the stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination." Additionally, in order to receive a diagnosis, "the stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder."
Intermittent explosive disorder
IED symptoms include "recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following: 1) Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals. 2) Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period." In order to receive an IED diagnosis, "the magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors," "the recurrent aggressive outbursts are not premeditated" and "are not committed to achieve some tangible objective." Additionally, to receive an IED diagnosis, an individual must be six years or older (chronologically or developmentally), have functional impairment, and not have symptoms better explained by another mental disorder, medical condition, or substance.
Substance use disorders
According to the DSM-5, "the essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems." Given that at least 10 separate classes of drugs are covered in the DSM-5 Substance-Related and Addictive Disorders section, it is outside the scope of this article. Refer to the DSM-5 for more information on signs and symptoms.
Comorbidity
Externalizing disorders are frequently comorbid or co-occurring with other disorders. Individuals who have the co-occurrence of more than one externalizing disorder have homotypic comorbidity, whereas individuals who have co-occurring externalizing and internalizing disorders have heterotypic comorbidity. It is not uncommon for children with early externalizing problems to develop both internalizing and further externalizing problems across the lifespan. Additionally, the complex interplay between externalizing and internalizing symptoms across development could explain the association between these problems and other risk behaviors, that typically initiate in adolescence (such as antisocial behaviors and substance use).
Stigma
Consistent with many mental disorders, individuals with externalizing disorders are subject to significant implicit and explicit forms of stigma. Because externalizing behaviors are salient and difficult to conceal, individuals with externalizing disorders may be more susceptible to stigmatization relative to individuals with other disorders. Parents of youth with childhood mental disorders, such as ADHD and ODD, are frequently stigmatized when parenting practices are strongly implicated in the etiology or cause of the disorder. Educational and policy-related initiatives have been proposed as potential mechanisms to reduce stigmatization of mental disorders.
Psychopathic traits
Individuals with psychopathic traits, including callous-unemotional (CU) traits, represent a phenomenologically and etiologically distinct group with severe externalizing problems. Psychopathic traits have been measured in children as young as two-years-old, are moderately stable, are heritable, and associated with atypical affective, cognitive, personality, and social characteristics. Individuals with psychopathic traits are at risk for poor response to treatment, however, some data suggest that parent management training interventions for youth with psychopathic traits early in development may have promise.
Developmental course
ADHD often precedes the onset of ODD, and approximately half of children with ADHD, combined type also have ODD. ODD is a risk factor for CD and frequently precedes the onset of CD symptoms. Children with an early onset of CD symptoms, with at least one symptom before age 10 years, are at risk for more severe and persistent antisocial behavior continuing into adulthood. Youth with early-onset conduct problems are particularly at risk for ASPD (note that an onset of CD prior to age 15 is part of the diagnostic criteria for ASPD), whereas CD is typically limited to adolescence when youth's CD symptoms begin during adolescence.
Treatment
Despite recent initiatives to study psychopathology along dimensions of behavior and neurobiological indices, which would help refine a clearer picture of the development and treatment of externalizing disorders, the majority of research has examined specific mental disorders. Thus, best practices for many externalizing disorders are disorder-specific. For example, substance use disorders themselves are very heterogeneous and their best-evidenced treatment typically includes cognitive behavioral therapy, motivational interviewing, and a substance disorder-specific detoxification or psychotropic medication treatment component. The best-evidenced treatment for childhood conduct and externalizing problems more broadly, including youth with ADHD, ODD, and CD, is parent management training, a form of cognitive behavioral therapy. Additionally, individuals with ADHD, both youth and adults, are frequently treated with stimulant medications (or alternative psychotropic medications), especially if psychotherapy alone has not been effective in managing symptoms and impairment. Psychotherapy and medication interventions for individuals with severe, adult forms of antisocial behavior, such as antisocial personality disorder, have been mostly ineffective. An individual's comorbid psychopathology may also influences the course of treatment for an individual.
History
The classification for several externalizing disorders changed from DSM-IV to DSM-5. ADHD, ODD, and CD were previously classified in the Attention-deficit and Disruptive Behavior Disorders section in DSM-IV. Pyromania, kleptomania, and IED were previously classified in the Impulse-Control Disorders Not Otherwise Specified Section of DSM-IV. ADHD is now categorized in the Neurodevelopmental Disorders section in DSM-5. ODD, CD, pyromania, kleptomania, and IED are now categorized in the new Disruptive, Impulse-Control, and Conduct Disorders chapter of DSM-5. Overall, there were many changes made to the DSM from the transition of DSM-IV-TR to DSM-5, which was somewhat controversial.
See also
Blasphemy
Heresy
Protest
Sedition
References
Types of mental disorders
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Human givens
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This is about psychotherapy. See Human condition for the general topic.
Human Givens is the name of a theory in psychotherapy formulated in the United Kingdom, first outlined by Joe Griffin and Ivan Tyrrell in the late 1990s, and amplified in the 2003 book Human Givens: A new approach to emotional health and clear thinking. The human givens organising ideas proffer a description of the nature of human beings, the 'givens' of human genetic heritage and what humans need in order to be happy and healthy based on the research literature.
Human Givens therapy draws on several psycho therapeutic models, such as motivational interviewing, cognitive behavioural therapy, psychoeducation, interpersonal therapy, imaginal exposure therapy and NLP such as the Rewind Technique, while seeking to use a client's strengths to enable them to get emotional needs met.
Historical background
Abraham Maslow is credited with the first prominent theory which laid out a hierarchy of needs. The precise nature of the hierarchy and the needs have subsequently been refined by modern neuroscientific and psychological research.
Since Maslow's work in the middle of the twentieth century, a significant body of research has been undertaken to clarify what human beings need to be happy and healthy. The UK has contributed significantly to the international effort, through the ground breaking Whitehall Study led by Sir Michael Marmot, which tracked the lifestyles and outcomes for large groups of British civil servants. This identified effects on mental and physical health from emotional needs being met - for instance, it showed that those with less autonomy and control over their lives, or less social support, have worse health outcomes.
In the United States, the work of Martin Seligman, a psychologist at the University of Pennsylvania has been influential. Seligman has summarised the research to date in terms of what makes humans happy; again, this demonstrates themes about universal emotional needs which must be met for people to lead fulfilling lives.
At the University of Rochester, contemporaries of Seligman Edward Deci and Richard Ryan have conducted original research and gathered existing evidence to develop a framework of human needs which they call self-determination theory. This states that human beings are born with innate motivations, developed from our evolutionary past. They gather these motivational forces into three groups - autonomy, competence and relatedness. The human givens approach uses a framework of nine needs, which map onto these three groups.
Innate needs
The human givens model proposes that human beings come into the world with a given set of innate needs, together with innate resources to support them to get those needs met. Physical needs for nutritious food, clean water, air and sleep are obvious, and well understood, because when they are not met people die. However, the emotional needs, which the human givens approach seeks to bring to wider attention, are less obvious, and less well understood, but just as important to human health. Decades of social and health psychology research now support this.
The human givens approach defines nine emotional needs:
Security: A sense of safety and security; safe territory; an environment in which people can live without experiencing excessive fear so that they can develop healthily.
Autonomy and control: A sense of autonomy and control over what happens around and to us.
Status: A sense of status - being accepted and valued in the various social groups we belong to.
Privacy: Time and space enough to reflect on and consolidate our experiences.
Attention: Receiving attention from others, but also giving it; a form of essential nutrition that fuels the development of each individual, family and culture.
Connection to the wider community: Interaction with a larger group of people and a sense of being part of the group.
Intimacy: Emotional connection to other people - friendship, love, intimacy, fun.
Competence and achievement: A sense of our own competence and achievements, that we have what it takes to meet life's demands.
Meaning and purpose: Being stretched, aiming for meaningful goals, having a sense of a higher calling or serving others creates meaning and purpose.
These needs map more or less well to tendencies and motivations described by other psychological evidence, especially that compiled by Deci and Ryan at the University of Rochester. The exact categorisation of these needs, however, is not considered important. Needs can be interlinked and have fuzzy boundaries, as Maslow noted. What matters is a broad understanding of the scope and nature of human emotional needs and why they are so important to our physical and mental health. Humans are a physically vulnerable species that have enjoyed amazing evolutionary success due in large part to their ability to form relationships and communities. Getting the right social and emotional input from others was, in our evolutionary past, literally a matter of life or death. Thus, Human Givens theory states, people are genetically programmed only to be happy and healthy when these needs are met.
There is evidence that these needs are consistent across cultures, and therefore represent innate human requirements.
Innate resources
The Human Givens model also consists of a set of 'resources' (abilities and capabilities) that all human beings are born with, which are used to get the innate needs met. These constitute what is termed an 'inner guidance system'. Learning how to use these resources well is seen as being key to achieving, and sustaining, robust bio-psycho-social health as individuals and as groups (families, communities, societies, cultures etc.).
The given resources include:
Memory: The ability to develop complex long-term memory, which enables people to add to their innate (instinctive) knowledge and learn;
Rapport: The ability to build rapport, empathise and connect with others;
Imagination: Which enables people to focus attention away from the emotions and problem solve more creatively and objectively (a 'reality simulator');
Instincts and emotions: A set of basic responses and 'propulsion' for behaviours;
A rational mind: A conscious, rational mind that can check out emotions, question, analyse and plan;
A metaphorical mind: The ability to 'know', to understand the world unconsciously through metaphorical pattern matching ('this thing is like that thing');
An observing self: That part of us which can step back, be more objective and recognise itself as a unique centre of awareness apart from intellect, emotion and conditioning;
A dreaming brain: According to the expectation fulfilment theory of dreaming, this preserves the integrity of our genetic inheritance every night by metaphorically defusing emotionally arousing expectations not acted out during the previous day.
Three reasons for mental illness
A further organising idea proffered by the human givens approach is to suggest that there are three main reasons why individuals may not be getting their needs met and thus why they may become mentally ill:
Environment: something in our environment is interfering with our ability to get our needs met. Our environment is 'toxic' (e.g. a bullying boss, antisocial neighbours) or simply lacks what we need (e.g. community);
Damage: something is wrong with our 'resources' -- our 'hardware' (brain/body) or 'software' (missing or incomplete instincts and/or unhelpful conditioning such as posttraumatic stress disorder) is damaged;
Knowledge: we may not know what we need; or we may not have been taught, or may have failed to learn, the coping skills necessary for getting our needs met (for example, how to use the imagination for problem solving rather than worrying, or how to make and sustain friendships).
When dealing with mental illness or distress this framework provides a checklist that guides both diagnosis and treatment.
Within this framework Joe Griffin and Ivan Tyrrell developed models for several forms of mental illness based on their own research and insights.
Depression - proposing expectation fulfilment theory of dreaming as the key to understanding the cycle of depression: how depression develops, is maintained and can be successfully treated.
Addiction
Autistic spectrum disorder - proposing caetextia as underlying mechanism
Psychosis - described as waking reality processed through the REM state/dreaming brain
Human givens therapy
Psychotherapy based on the Human Givens theory follows the APET model, following the order in which the brain processes information and offers supportive strategies for each phase.
Activating agent - a stimulus
Pattern match - a past event
Emotions
Thoughts
Sessions are structured by the RIGAAR model.
Rapport building
Information gathering
Goal setting (new, positive expectations related to the fulfillment of innate needs)
Accessing resources
Agreeing on strategies for change (for achieving the needs-related goals)
Rehearsing success
Human Givens therapy is a solution-focused brief therapy, an approach that is aligned with solution-focused coaching and wellness coaching, and thus the Human Givens approach is used by psychotherapists as well as life coaches and therapeutic coaches.
Efficacy and criticisms
In 2008, a systematic review of the literature on the Human Givens approach concluded that the evidence was limited and of low quality. They called for rigorously designed studies. They did find 2 studies of higher quality evidence supporting the rewind technique but attributed the rewind technique rather than the Human Givens approach. The authors called on mainstream journals to provide space for healthy debate.
In 2012 a retrospective review of 3,885 cases found Human Givens Therapy to be clinically equivalent to a benchmark for relief from psychological distress.
A controlled study found that treating people with mild to moderate depressed mood (measured using HADS) with human givens therapy had quicker results than the treatment provided to people in a control group, but suffered problems reaching an adequately sized control group.
A five-year evaluation of the Human Givens therapy using a practice research network found success with relieving psychological distress.
In 2019 a retrospective study found that a Human Givens based therapy provided by PTSD Resolution for the Armed Forces Community was to be an acceptable alternative for IAPT treatment. The therapy offered by PTSD Resolution is based on the rewind technique as adopted by Human Givens.
See also
Maslow's hierarchy of needs
Manfred Max-Neef's Fundamental human needs
Ivan Tyrrell
References
External links
The Human Givens Institute
The Human Givens Foundation
Human Givens College
Caetextia (context blindness)
1998 introductions
Psychotherapeutical theories
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Destabilisation
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The word destabilisation (alternatively, destabilization) can be applied to a wide variety of contexts such as attempts to undermine political, military or economic power.
Psychology
In a psychological context, it is used as a technique in brainwashing and abuse to disorient and disarm the victim.
In the context of workplace bullying, destabilisation applied to the victim may involve:
failure to acknowledge good work and value the victim's efforts
allocation of meaningless tasks
removal of areas of responsibility without consultation
repeated reminders of blunders
setting up to fail
shifting of goal posts without telling the victim
persistent attempts to demoralise the victim
Destabilisation could also denote the extreme end of disinhibition syndrome and entail the complete shutdown of an individual's control of emotions, inhibitions, and productive functioning. The condition can be episodic or it could last for months or years, requiring professional care from a practitioner who is familiar with the individual's primary neurological disorder.
In psychology, there is also a process called cognitive destabilisation, which involves being open to conversions and transformations of various kinds. This could be used to counter political destabilisation by presenting a consensual view of the problem.
Other applications
Destabilisation is also used in the feminist context such as the way it is used to change the binary opposition between men and women, particularly how it gives the category 'woman' its meaning. For instance, this is expressed in many feminists' discomfort concerning postmodern theories' challenge to traditional binary oppositions, perceiving it as a subversion of women's attempt to define their own subjecthood. The body of literature on feminism also often invoke the need to destabilise modern theory, particularly the theoretical discourses that claim neutrality but are established from a masculine perspective. These attempts to destabilise modern female constructs have been informed by Jacques Derrida's deconstruction theory, particularly the destabilisation of positions and subjects that have been deemed holistic or authoritative.
In literature, a conceptualization refers to it as an aggression or a kind of attack on the reader to provoke discomfort. In international capital transactions, it is used to denote as a capital movement driven by erroneous forecast, driving the exchange rate away from equilibrium that would be supported by rational speculators whose foresight are correct.
See also
References
Further reading
Deception
Mind control
Psychological abuse
Harassment and bullying
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Conceptual proliferation
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In Buddhism, conceptual proliferation (Pāli: ; Sanskrit: ; ; ) or, alternatively, mental proliferation or conceptual elaboration, refers to conceptualization of the world through language and concepts which can then be a cause for suffering to arise. The translation of papañca as conceptual proliferation was first made by Katukurunde Nyanananda Thera in his research monograph Concept and Reality.
The term is mentioned in a variety of suttas in the Pali canon, such as the Madhupindika Sutta (MN 18), and is mentioned in Mahayana Buddhism as well. When referencing the concepts derived from this process, such concepts are referred to in Pali as papañca-saññā-sankhā. Nippapañca is the diametrical opposition of papañca.
Theravada Buddhist monk Chandima Gangodawila writes:
Papañca is one of the most helpful Theravāda Buddhist teachings used to understand how our thoughts become impure and the most compelling account of this subject is the Madhupiṇḍika Sutta. Since many writers don't utilize papañca when alluding to defilements, many readers discover the setting of mental purification hard to understand. If we seriously want to learn how to keep our mental purification unadulterated from defilements, we should figure out how the mental purification can be tainted through papañca.
In addition, Chandima examines the association of papañca to kilesa (defilements), upakkilesa (mental impurities), saññā (perceptions) and abhiññā (comprehensions) to find out whether or not the essential components of mental purification begin from managing papañca, or the other dhamma concepts, that can be bold for anyone who struggles to subsume defilements in modern-day life.
See also
Make a mountain out of a molehill
Monkey mind
Nibbāna: The Mind Stilled
Reification (fallacy)
References
External links
Exploring the Honeyball Sutta, An Alternative Nidana Chain
Getting Away From Prapanca, The Practical Applications of the Honeyball Sutta
Dharma talk on papañca by Christina Feldman
Buddhist philosophical concepts
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Focusing (psychotherapy)
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Focusing is an internally oriented psychotherapeutic process developed by psychotherapist Eugene Gendlin. It can be used in any kind of therapeutic situation, including peer-to-peer sessions. It involves holding a specific kind of open, non-judging attention to an internal knowing which is experienced but is not yet in words. Focusing can, among other things, be used to become clear on what one feels or wants, to obtain new insights about one's situation, and to stimulate change or healing of the situation. Focusing is set apart from other methods of inner awareness by three qualities: something called the "felt sense", a quality of engaged accepting attention, and a research-based technique that facilitates change.
Origin
At the University of Chicago, beginning in 1953, Eugene Gendlin did 15 years of research analyzing what made psychotherapy either successful or unsuccessful. His conclusion was that it is not the therapist's technique that determines the success of psychotherapy, but rather the way the patient behaves, and what the patient does inside himself during the therapy sessions. Gendlin found that, without exception, the successful patient intuitively focuses inside himself on a very subtle and vague internal bodily awareness—or "felt sense"—which contains information that, if attended to or focused on, holds the key to the resolution of the problems the patient is experiencing.
"Focusing" is a process and learnable skill developed by Gendlin which re-creates this successful-patient behavior in a form that can be taught to other patients. Gendlin detailed the techniques in his book Focusing which, intended for the layperson, is written in conversational terms and describes the six steps of Focusing and how to do them. Gendlin stated: "I did not invent Focusing. I simply made some steps which help people to find Focusing."
"Felt sense" and "felt shift"
Gendlin gave the name "felt sense" to the unclear, pre-verbal sense of "something"—the inner knowledge or awareness that has not been consciously thought or verbalized—as that "something" is experienced in the body. It is not the same as an emotion. This bodily felt "something" may be an awareness of a situation or an old hurt, or of something that is "coming"—perhaps an idea or insight. Crucial to the concept, as defined by Gendlin, is that it is unclear and vague, and it is always more than any attempt to express it verbally. Gendlin also described it as "sensing an implicit complexity, a wholistic sense of what one is working on".
According to Gendlin, the Focusing process makes a felt sense more tangible and easier to work with. To help the felt sense form and to accurately identify its meaning, the focuser tries out words that might express it. These words can be tested against the felt sense: The felt sense will not resonate with a word or phrase that does not adequately describe it.
Gendlin observed clients, writers, and people in ordinary life ("Focusers") turning their attention to this not-yet-articulated knowing. As a felt sense formed, there would be long pauses together with sounds like "uh...." Once the person had accurately identified this felt sense in words, new words would come, and new insights into the situation. There would be a sense of felt movement—a "felt shift"—and the person would begin to be able to move beyond the "stuck" place, having fresh insights, and also sometimes indications of steps to take.
Learning and using Focusing
One can learn the Focusing technique from one of several books, or from a Focusing trainer, practitioner, or therapist. Focusing is easiest to sense and do in the presence of a "listener"—either a Focusing trainer, a therapist, or a layperson trained in Focusing. However, the practice can be done alone. Gendlin's book details the six steps of Focusing, however it emphasizes that the essence of Focusing is not adhering to these steps, but following the organic process. When the person learns the basics, they are able to weave through the process increasingly more and more organically.
Focusing is now practiced all over the world by thousands of people—both in professional settings with Focusing trainers, and informally between laypersons. As a stand-alone process, a Focusing session can last from approximately 10 minutes to an hour, on average—with the "focuser" being listened to, and their verbalized thoughts and feelings being reflected back by the "listener". Generally speaking, but not always, the focuser has their eyes closed, in order to more accurately focus inwardly on their "felt sense" and the shifts that take place from it.
Subsequent developments
In 1996, Gendlin published a comprehensive book on Focusing-oriented psychotherapy. The Focusing-oriented psychotherapist attributes a central importance to the client's capacity to be aware of their "felt sense" and the meaning behind their words or images. The client is encouraged to sense into feelings and meanings which are not yet formed. Other elements of Focusing are also incorporated into the therapy practice so that Focusing remains the basis of the process—allowing for inner resonance and verification of ideas and feelings, and allowing new and fresh insights to come from within the client.
Several adaptations of Gendlin's original six-step Focusing process have been developed. The most popular and prevalent of these is the process Ann Weiser Cornell teaches, called Inner Relationship Focusing.
Other developments in Focusing include focusing alone using a journal or a sketchbook. Drawing and painting can be used with Focusing processes with children. Focusing also happens in other domains besides therapy. Attention to the felt sense naturally takes place in all manner of processes where something new is being formed: for example in creative process, learning, thinking, and decision making.
See also
Emotion-focused therapy
Internal Family Systems Model
Intuition (mind)
Method of levels
Nonviolent Communication
References
Further reading
External links
International Focusing Institute
Focusing-Oriented Psychotherapy
British Focusing Association
Psychotherapy
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Occupational hygiene
|
Occupational hygiene or industrial hygiene (IH) is the anticipation, recognition, evaluation, control, and confirmation (ARECC) of protection from risks associated with exposures to hazards in, or arising from, the workplace that may result in injury, illness, impairment, or affect the well-being of workers and members of the community. These hazards or stressors are typically divided into the categories biological, chemical, physical, ergonomic and psychosocial. The risk of a health effect from a given stressor is a function of the hazard multiplied by the exposure to the individual or group. For chemicals, the hazard can be understood by the dose response profile most often based on toxicological studies or models. Occupational hygienists work closely with toxicologists (see Toxicology) for understanding chemical hazards, physicists (see Physics) for physical hazards, and physicians and microbiologists for biological hazards (see Microbiology, Tropical medicine, Infection). Environmental and occupational hygienists are considered experts in exposure science and exposure risk management. Depending on an individual's type of job, a hygienist will apply their exposure science expertise for the protection of workers, consumers and/or communities.
The profession of occupational hygienist
The British Occupational Hygiene Society (BOHS) defines that "occupational hygiene is about the prevention of ill-health from work, through recognizing, evaluating and controlling the risks". The International Occupational Hygiene Association (IOHA) refers to occupational hygiene as the discipline of anticipating, recognizing, evaluating and controlling health hazards in the working environment with the objective of protecting worker health and well-being and safeguarding the community at large. The term occupational hygiene (used in the UK and Commonwealth countries as well as much of Europe) is synonymous with industrial hygiene (used in the US, Latin America, and other countries that received initial technical support or training from US sources). The term industrial hygiene traditionally stems from industries with construction, mining or manufacturing, and occupational hygiene refers to all types of industry such as those listed for industrial hygiene as well as financial and support services industries and refers to "work", "workplace" and "place of work" in general. Environmental hygiene addresses similar issues to occupational hygiene but is likely to be about broad industry or broad issues affecting the local community, broader society, region or country.
The profession of occupational hygiene uses strict and rigorous scientific methodology and often requires professional judgment based on experience and education in determining the potential for hazardous exposure risks in workplace and environmental studies. These aspects of occupational hygiene can often be referred to as the "art" of occupational hygiene and is used in a similar sense to the "art" of medicine. In fact "occupational hygiene" is both an aspect of preventive medicine and in particular occupational medicine, in that its goal is to prevent industrial disease, using the science of risk management, exposure assessment and industrial safety. Ultimately professionals seek to implement "safe" systems, procedures or methods to be applied in the workplace or to the environment. Prevention of exposure to long working hours has been identified as a focus for occupational hygiene when a landmark United Nations study estimated that this occupational hazard causes an estimated 745,000 occupational fatalities per year worldwide, the largest burden of disease attributed to any single occupational hazard.
Industrial hygiene refers to the science of anticipating, recognizing, evaluating, and controlling workplaces to prevent illness or injuries to the workers. Industrial hygienists use various environmental monitoring and analytical methods to establish how workers are exposed. In turn, they employ techniques such as engineering and work practice controls to control any potential health hazards.
Anticipation involves identifying potential hazards in the workplace before they are introduced. The uncertainty of health hazards ranges from reasonable expectations to mere speculations. However, it implies that the industrial hygienist must understand the nature of changes in the processes, products, environments, and workforces of the workplaces and how they can affect workers' well-being.
Recognition of engineering, work practice, and administrative controls are the primary means of reducing the workers` exposure to occupational hazards. Timely recognition of hazards minimizes the workers' exposure to the hazards by removing or reducing the hazard's source or isolating the workers from the hazards.
Evaluation of a worksite is a significant step that helps the industrial hygienists establish jobs and worksites that are a potential source of problems. During the evaluation, the industrial hygienist measures and identifies the problem tasks, exposures, and tasks. The most effective worksites assessment includes all the jobs, work activities, and operations. The industrial hygienists inspect research and evaluations of how given physical or chemical hazards affect the workers' health. If the workplace contains a health hazard, the industrial hygienist recommends appropriate corrective actions.
Control measures include removing toxic chemicals and replacing harmful toxic materials with less hazardous ones. It also involves confining work operations or enclosing work processes and installing general and local ventilation systems. Controls change how the task is performed. Some of the basic work practice controls include: following the laid procedures to reduce exposures while at the workplace, inspecting and maintaining processes regularly, and implementing reasonable workplace procedures.
History
The industrial hygiene profession gained respectability back in 1700 when Bernardino Ramazzini published a comprehensive book on industrial medicine. The book was written in Italian and was known as De Morbis Artificum Diatriba, meaning “The Diseases of Workmen”. The book detailed the accurate description of the occupational diseases that most of his time workers suffered from. Ramazzini was critical to the industrial hygiene profession's future because he asserted that occupational diseases should be studied in the workplace environment and not in hospital wards.
Industrial hygiene in the United States started taking shape in the early 20th century. There before, many workers risked their lives daily to work in industrial settings such as manufacturing, mills, constructions, and mines. Currently, the statistics on work safety are usually measured by the number of injuries and deaths yearly. Before the 20th century, these kinds of statistics were hard to come by because it appeared no one cared enough to make tracking of the job injuries and deaths a priority.
Industrial hygiene received another boost in the early 20th century when Alice Hamilton led an effort to improve industrial hygiene. She began by observing industrial conditions first and then startled mine owners, factory managers, and other state officials with evidence that there was a correlation between workers' illnesses and their exposure to chemical toxins. She presented definitive proposals for eliminating unhealthful working conditions. As a result, the US federal government also began investigating health conditions in the industry. In 1911, the states passed the first workers' compensation laws.
The social role of occupational hygiene
Occupational hygienists have been involved historically with changing the perception of society about the nature and extent of hazards and preventing exposures in the workplace and communities. Many occupational hygienists work day-to-day with industrial situations that require control or improvement to the workplace situation. However larger social issues affecting whole industries have occurred in the past e.g. since 1900, asbestos exposures that have affected the lives of tens of thousands of people. Occupational hygienists have become more engaged in understanding and managing exposure risks to consumers from products with regulations such as REACh (Registration, Evaluation, Authorisation and Restriction of Chemicals) enacted in 2006.
More recent issues affecting broader society are, for example in 1976, Legionnaires' disease or legionellosis. More recently again in the 1990s, radon, and in the 2000s, the effects of mold from indoor air quality situations in the home and at work. In the later part of the 2000s, concern has been raised about the health effects of nanoparticles.
Many of these issues have required the coordination of medical and paraprofessionals in detecting and then characterizing the nature of the issue, both in terms of the hazard and in terms of the risk to the workplace and ultimately to society. This has involved occupational hygienists in research, collection of data and development of suitable and satisfactory control methodologies.
General activities
The occupational hygienist may be involved with the assessment and control of physical, chemical, biological or environmental hazards in the workplace or community that could cause injury or disease. Physical hazards may include noise, temperature extremes, illumination extremes, ionizing or non-ionizing radiation, and ergonomics. Chemical hazards related to dangerous goods or hazardous substances are frequently investigated by occupational hygienists. Other related areas including indoor air quality (IAQ) and safety may also receive the attention of the occupational hygienist. Biological hazards may stem from the potential for legionella exposure at work or the investigation of biological injury or effects at work, such as dermatitis may be investigated.
As part of the investigation process, the occupational hygienist may be called upon to communicate effectively regarding the nature of the hazard, the potential for risk, and the appropriate methods of control. Appropriate controls are selected from the hierarchy of control: by elimination, substitution, engineering, administration and personal protective equipment (PPE) to control the hazard or eliminate the risk. Such controls may involve recommendations as simple as appropriate PPE such as a 'basic' particulate dust mask to occasionally designing dust extraction ventilation systems, work places or management systems to manage people and programs for the preservation of health and well-being of those who enter a workplace.
Examples of occupational hygiene include:
Analysis of physical hazards such as noise, which may require use of hearing protection earplugs and/or earmuffs to prevent hearing loss.
Developing plans and procedures to protect against infectious disease exposure in the event of a flu pandemic.
Monitoring the air for hazardous contaminants which may potentially lead to worker illness or death.
Workplace assessment methods
Although there are many aspects to occupational hygiene work the most known and sought after is in determining or estimating potential or actual exposures to hazards. For many chemicals and physical hazards, occupational exposure limits have been derived using toxicological, epidemiological and medical data allowing hygienists to reduce the risks of health effects by implementing the "Hierarchy of Hazard Controls". Several methods can be applied in assessing the workplace or environment for exposure to a known or suspected hazard. Occupational hygienists do not rely on the accuracy of the equipment or method used but in knowing with certainty and precision the limits of the equipment or method being used and the error or variance given by using that particular equipment or method. Well known methods for performing occupational exposure assessments can be found in the book A Strategy for Assessing and Managing Occupational Exposures, published by AIHA Press.
The main steps outlined for assessing and managing occupational exposures:
Basic Characterization (identify agents, hazards, people potentially exposed and existing exposure controls)
Exposure Assessment (select occupational exposure limits, hazard bands, relevant toxicological data to determine if exposures are "acceptable", "unacceptable" or "uncertain")
Exposure Controls (for "unacceptable" or "uncertain" exposures)
Further Information Gathering (for "uncertain" exposures)
Hazard Communication (for all exposures)
Reassessment (as needed) / Management of Change
Basic characterization, hazard identification and walk-through surveys
The first step in understanding health risks related to exposures requires the collection of "basic characterization" information from available sources. A traditional method applied by occupational hygienists to initially survey a workplace or environment is used to determine both the types and possible exposures from hazards (e.g. noise, chemicals, radiation). The walk-through survey can be targeted or limited to particular hazards such as silica dust, or noise, to focus attention on control of all hazards to workers. A full walk-through survey is frequently used to provide information on establishing a framework for future investigations, prioritizing hazards, determining the requirements for measurement and establishing some immediate control of potential exposures. The Health Hazard Evaluation Program from the National Institute for Occupational Safety and Health is an example of an industrial hygiene walk-through survey. Other sources of basic characterization information include worker interviews, observing exposure tasks, material safety data sheets, workforce scheduling, production data, equipment and maintenance schedules to identify potential exposure agents and people possibly exposed.
The information that needs to be gathered from sources should apply to the specific type of work from which the hazards can come from. As mentioned previously, examples of these sources include interviews with people who have worked in the field of the hazard, history and analysis of past incidents, and official reports of work and the hazards encountered. Of these, the personnel interviews may be the most critical in identifying undocumented practices, events, releases, hazards and other relevant information. Once the information is gathered from a collection of sources, it is recommended for these to be digitally archived (to allow for quick searching) and to have a physical set of the same information in order for it to be more accessible. One innovative way to display the complex historical hazard information is with a historical hazards identification map, which distills the hazard information into an easy to use graphical format.
Sampling
An occupational hygienist may use one or a number of commercially available electronic measuring devices to measure noise, vibration, ionizing and non-ionizing radiation, dust, solvents, gases, and so on. Each device is often specifically designed to measure a specific or particular type of contaminant. Electronic devices need to be calibrated before and after use to ensure the accuracy of the measurements taken and often require a system of certifying the precision of the instrument.
Collecting occupational exposure data is resource- and time-intensive, and can be used for different purposes, including evaluating compliance with government regulations and for planning preventive interventions. The usability of occupational exposure data is influenced by these factors:
Data storage (e.g. use of electronic and centralized databases with retention of all records)
Standardization of data collection
Collaboration between researchers, safety and health professionals and insurers
In 2018, in an effort to standardize industrial hygiene data collection among workers compensation insurers and to determine the feasibility of pooling collected IH data, IH air and noise survey forms were collected. Data fields were evaluated for importance and a study list of core fields was developed, and submitted to an expert panel for review before finalization. The final core study list was compared to recommendations published by the American Conference of Governmental Industrial Hygienists (ACGIH) and the American Industrial Hygiene Association (AIHA). Data fields essential to standardizing IH data collection were identified and verified. The "essential" data fields are available and could contribute to improved data quality and its management if incorporated into IH data management systems.
Canada and several European countries have been working to establish occupational exposure databases with standardized data elements and improved data quality. These databases include MEGA, COLCHIC, and CWED.
Dust sampling
Nuisance dust is considered to be the total dust in air including inhalable and respirable fractions.
Various dust sampling methods exist that are internationally recognised. Inhalable dust is determined using the modern equivalent of the Institute of Occupational Medicine (IOM) MRE 113A monitor. Inhalable dust is considered to be dust of less than 100 micrometers aerodynamic equivalent diameter (AED) that enters through the nose and or mouth.
Respirable dust is sampled using a cyclone dust sampler design to sample for a specific fraction of dust AED at a set flow rate. The respirable dust fraction is dust that enters the 'deep lung' and is considered to be less than 10 micrometers AED.
Nuisance, inhalable and respirable dust fractions are all sampled using a constant volumetric pump for a specific sampling period. By knowing the mass of the sample collected and the volume of air sampled, a concentration for the fraction sampled can be given in milligrams (mg) per meter cubed (m3). From such samples, the amount of inhalable or respirable dust can be determined and compared to the relevant occupational exposure limits.
By use of inhalable, respirable or other suitable sampler (7 hole, 5 hole, etc.), these dust sampling methods can also used to determine metal exposure in the air. This requires collection of the sample on a methyl cellulose ester (MCE) filter and acid digestion of the collection media in the laboratory followed by measuring metal concentration through atomic absorption spectroscopy or atomic emission spectroscopy. Both the UK Health and Safety Laboratory and NIOSH Manual of Analytical Methods have specific methodologies for a broad range of metals in air found in industrial processing (smelting, foundries, etc.).
A further method exists for the determination of asbestos, fiberglass, synthetic mineral fiber and ceramic mineral fiber dust in air. This is the membrane filter method (MFM) and requires the collection of the dust on a gridded filter for estimation of exposure by the counting of 'conforming' fibers in 100 fields through a microscope. Results are quantified on the basis of number of fibers per milliliter of air (f/mL). Many countries strictly regulate the methodology applied to the MFM.
Chemical sampling
Two types of chemically absorbent tubes are used to sample for a wide range of chemical substances. Traditionally a chemical absorbent 'tube' (a glass or stainless steel tube of between 2 and 10 mm internal diameter) filled with very fine absorbent silica (hydrophilic) or carbon, such as coconut charcoal (lipophilic), is used in a sampling line where air is drawn through the absorbent material for between four hours (minimum workplace sample) to 24 hours (environmental sample) period. The hydrophilic material readily absorbs water-soluble chemical and the lipophilic material absorbs non water-soluble materials. The absorbent material is then chemically or physically extracted and measurements performed using various gas chromatography or mass spectrometry methods. These absorbent tube methods have the advantage of being usable for a wide range of potential contaminates. However, they are relatively expensive methods, are time-consuming and require significant expertise in sampling and chemical analysis. A frequent complaint of workers is in having to wear the sampling pump (up to 1 kg) for several days of work to provide adequate data for the required statistical certainty determination of the exposure.
In the last few decades, advances have been made in 'passive' badge technology. These samplers can now be purchased to measure one chemical (e.g. formaldehyde) or a chemical type (e.g. ketones) or a broad spectrum of chemicals (e.g. solvents). They are relatively easy to set up and use. However, considerable cost can still be incurred in analysis of the 'badge'. They weigh 20 to 30 grams and workers do not complain about their presence. Unfortunately 'badges' may not exist for all types of workplace sampling that may be required, and the charcoal or silica method may sometimes have to be applied.
From the sampling method, results are expressed in milligrams per cubic meter (mg/m3) or parts per million (PPM) and compared to the relevant occupational exposure limits.
It is a critical part of the exposure determination that the method of sampling for the specific contaminate exposure is directly linked to the exposure standard used. Many countries regulate both the exposure standard, the method used to determine the exposure and the methods to be used for chemical or other analysis of the samples collected.
Noise sampling
Two types of noise are environmental noise, which is unwanted sound that occurs outdoors, and occupational noise, the sound that is received by employees while they are in the workplace. Environmental noise can originate from various sources depending on the activity, location, and time. Environmental noise can be generated from transportation such as road, rail, and air traffic, or construction and building services, and even domestic and leisure activities.
There is a legal limit on noise that the environmental noise is 70 dB(A) over 24 hours of average exposure. Similarly, the limit of occupational noise is 85 dB(A) per NIOSH, or 90 dB(A) per OSHA for an 8-hour work period. In order to enforce these limits, these are the methods to measure noise, including sound level meter (SLM), Sound Level Meter App, integrating sound level meter (ISLM), impulse sound level meter (Impulse SLM), noise dosimeter, and personal sound exposure meter (PSEM).
Sound level meter (SLM): measures the sound level at a single point of time and consequently requires multiple measurements to be taken at different times of the day. The SLM is primarily used for measuring relatively stable sound levels; there is increased difficulty in measuring the average sound exposure if the noise levels vary greatly.
Sound Level Meter App is a program that can be downloaded to a mobile device. It receives noise through the phone's built-in or external microphone and displays the sound level measurement from the app's sound level meters and noise dosimeters.
Integrating sound level meter (ISLM): measures the equivalent sound levels within the measurement period. Because the ISLM measures noise in a particular area, it is difficult to measure a worker's personal exposure as they move throughout a workspace.
Impulse sound level meter (Impulse SLM): measures the peak of each sound impulse. The most optimal conditions to measure the peaks occur when there is little background noise.
Noise dosimeter: collects the sound level for a given point in time, as well as different sound levels across time. The noise dosimeter can measure personal exposure levels and can be used in the areas with a high risk of fire.
Personal sound exposure meter (PSEM): worn by employees while they work. The advantage of the PSEM is that it eliminates the need for noise assessors to follow up with workers when the assessors measure the noise levels of the work areas.
Excessive noise can lead to occupational hearing loss. 12% of workers report having hearing difficulties, making this the third most common chronic disease in the U.S. Among these workers, 24% have hearing difficulties caused by occupational noise, with 8% affected by tinnitus, and 4% having both hearing difficulties and tinnitus.
Ototoxic chemicals including solvents, metals, compounds, asphyxiants, nitriles, and pharmaceuticals, may contribute further to hearing loss.
Exposure management and controls
The hierarchy of control defines the approach used to reduce exposure risks protecting workers and communities. These methods include elimination, substitution, engineering controls (isolation or ventilation), administrative controls and personal protective equipment. Occupational hygienists, engineers, maintenance, management and employees should all be consulted for selecting and designing the most effective and efficient controls based on the hierarchy of control.
Professional societies
The development of industrial hygiene societies originated in the United States, beginning with the first convening of members for the American Conference of Governmental Industrial Hygienists in 1938, and the formation of the American Industrial Hygiene Association in 1939. In the United Kingdom, the British Occupational Hygiene Society started in 1953. Through the years, professional occupational societies have formed in many different countries, leading to the formation of the International Occupational Hygiene Association in 1987, in order to promote and develop occupational hygiene worldwide through the member organizations. The IOHA has grown to 29 member organizations, representing over 20,000 occupational hygienists worldwide, with representation from countries present in every continent.
Peer-reviewed literature
There are several academic journals specifically focused on publishing studies and research in the occupational health field. The Journal of Occupational and Environmental Hygiene (JOEH) has been published jointly since 2004 by the American Industrial Hygiene Association and the American Conference of Governmental Industrial Hygienists, replacing the former American Industrial Hygiene Association Journal and Applied Occupational & Environmental Hygiene journals. Another seminal occupational hygiene journal would be The Annals of Occupational Hygiene, published by the British Occupational Hygiene Society since 1958. Further, NIOSH maintains a searchable bibliographic database (NIOSHTIC-2) of occupational safety and health publications, documents, grant reports, and other communication products.
Occupational hygiene as a career
Examples of occupational hygiene careers include:
Compliance officer on behalf of regulatory agency
Professional working on behalf of company for the protection of the workforce
Consultant working on behalf of companies
Researcher performing laboratory or field occupational hygiene work
Education
The basis of the technical knowledge of occupational hygiene is from competent training in the following areas of science and management:
Basic sciences (biology, chemistry, mathematics (statistics), physics)
Occupational diseases (illness, injury and health surveillance (biostatistics, epidemiology, toxicology))
Health hazards (biological, chemical and physical hazards, ergonomics and human factors)
Working environments (mining, industrial, manufacturing, transport and storage, service industries and offices)
Programme management principles (professional and business ethics, work site and incident investigation methods, exposure guidelines, occupational exposure limits, jurisdictional based regulations, hazard identification, risk assessment and risk communication, data management, fire evacuation and other emergency responses)
Sampling, measurement and evaluation practices (instrumentation, sampling protocols, methods or techniques, analytical chemistry)
Hazard controls (elimination, substitution, engineering, administrative, PPE and air conditioning and extraction ventilation)
Environment (air pollution, hazardous waste)
However, it is not rote knowledge that identifies a competent occupational hygienist. There is an "art" to applying the technical principles in a manner that provides a reasonable solution for workplace and environmental issues. In effect an experienced "mentor", who has experience in occupational hygiene is required to show a new occupational hygienist how to apply the learned scientific and management knowledge in the workplace and to the environment issue to satisfactorily resolve the problem.
To be a professional occupational hygienist, experience in as wide a practice as possible is required to demonstrate knowledge in areas of occupational hygiene. This is difficult for "specialists" or those who practice in narrow subject areas. Limiting experience to individual subject like asbestos remediation, confined spaces, indoor air quality, or lead abatement, or learning only through a textbook or “review course” can be a disadvantage when required to demonstrate competence in other areas of occupational hygiene.
Information presented in Wikipedia can be considered to be only an outline of the requirements for professional occupational hygiene training. This is because the actual requirements in any country, state or region may vary due to educational resources available, industry demand or regulatory mandated requirements.
During 2010, the Occupational Hygiene Training Association (OHTA) through sponsorship provided by the IOHA initiated a training scheme for those with an interest in or those requiring training in occupational hygiene. These training modules can be downloaded and used freely. The available subject modules (Basic Principles in Occupational Hygiene, Health Effects of Hazardous Substances, Measurement of Hazardous Substances, Thermal Environment, Noise, Asbestos, Control, Ergonomics) are aimed at the ‘foundation’ and ‘intermediate’ levels in occupational hygiene. Although the modules can be used freely without supervision, attendance at an accredited training course is encouraged. These training modules are available from ohtatraining.org
Academic programs offering industrial hygiene bachelor's or master's degrees in United States may apply to the Accreditation Board for Engineering and Technology (ABET) to have their program accredited. As of October 1, 2006, 27 institutions have accredited their industrial hygiene programs. Accreditation is not available for doctoral programs.
In the U.S., the training of IH professionals is supported by NIOSH through their NIOSH Education and Research Centers.
Professional credentials
Australia
In 2005, the Australian Institute of Occupational Hygiene (AIOH) accredited professional occupational hygienists through a certification scheme. Occupational Hygienists in Australia certified through this scheme are entitled to use the phrase Certified Occupational Hygienist (COH) as part of their qualifications.
Hong Kong
Registered Professional Hygienist Registration & Examination Board (RPH R&EB) is set up by the Council of the Hong Kong Institute of Occupational & Environmental Hygiene (HKIOEH) with an aim to enhance the professional development of occupational hygienists and to provide a path for persons who reach professional maturity in the field of occupational hygiene to obtain qualification recognised by peer professionals. Under HKIOEH, RPH R&EB operates the registration program of Registered Professional Hygienist (RPH) and qualifying examination in a standard meeting the practice as recognised by the National Accreditation Recognition (NAR) Committee of the International Occupational Hygiene Association (IOHA).
Saudi Arabia
The Saudi Arabian Ministry of Health's Occupational Health Directorate and Labor Office are the government agencies responsible for decisions and surveillance related to occupational hygiene. Professional occupational hygiene and safety education programs surveilled under these offices are available through Saudi Arabian colleges.
United States
Practitioners who successfully meet specific education and work-experience requirements and pass a written examination administered by the Board for Global EHS Credentialing (BGC) are authorized to use the term Certified Industrial Hygienist (CIH) or the discontinued Certified Associate Industrial Hygienist (CAIH). Both of these terms have been codified into law in many states in the United States to identify minimum qualifications of individuals having oversight over certain activities that may affect employee and general public health.
After the initial certification, the CIH or CAIH maintains their certification by meeting on-going requirements for ethical behavior, education, and professional activities (e.g., active practice, technical committees, publishing, teaching).
Certification examinations are offered during a spring and fall testing window each year worldwide.
The CIH designation is the most well known and recognized industrial hygiene designation throughout the world. There are approximately 6800 CIHs in the world making BGC the largest industrial hygiene certification organization. The CAIH certification program was discontinued in 2006. Those who were certified as a CAIH retain their certification through ongoing certification maintenance. People who are currently certified by BGC can be found in a public roster.
The BGC is a recognized certification board by the International Occupational Hygiene Association (IOHA). The CIH certification has been accredited internationally by the International Organization for Standardization/International Electrotechnical Commission (ISO/IEC 17024). In the United States, the CIH has been accredited by the Council of Engineering and Scientific Specialty Boards (CESB).
Canada
In Canada, a practitioner who successfully completes a written test and an interview administered by the Canadian Registration Board of Occupational Hygienists can be recognized as a Registered Occupational Hygienist (ROH) or Registered Occupational Hygiene Technician (ROHT). There is also designation to be recognized as a Canadian Registered Safety Professional (CRSP).
United Kingdom
The Faculty of Occupational Hygiene, part of the British Occupational Hygiene Society, represents the interests of professional occupational hygienists.
Membership of the Faculty of Occupational Hygiene is confined to BOHS members who hold a recognized professional qualification in occupational hygiene.
There are three grades of Faculty membership:
Licentiate (LFOH) holders will have obtained the BOHS Certificate of Operational Competence in Occupational Hygiene and have at least three years’ practical experience in the field.
Members (MFOH) are normally holders of the Diploma of Professional Competence in Occupational Hygiene and have at least five years’ experience at a senior level.
Fellows (FFOH) are senior members of the profession who have made a distinct contribution to the advancement of occupational hygiene.
All Faculty members participate in a Continuous Professional Development (CPD) scheme designed to maintain a high level of current awareness and knowledge in occupational hygiene.
India
The Indian Society of Industrial hygiene was formed in 1981 at Chennai, India. Subsequently, its secretariat was shifted to Kanpur. The society has registered about 400 members, about 90 of whom are life members. The society publishes a newsletter, "Industrial Hygiene Link". The current address of the secretary of the society is Shyam Singh Gautam, Secretary, Indian Society of Industrial Hygiene, 11, Shakti Nagar, Rama Devi, Kanpur 2008005 Mobile number 8005187037.
See also
References
Further reading
World Health Organization Occupational Health Publications
International Labour Organization Encyclopaedia of Occupational Health and Safety, [1]
UK HSEline
EPA Indoor Air Quality on-line educator
Canada hazard information
A list of MSDS sites (Partly commercial)
(US) NIOSH Pocket Guide
(US) Agency for Toxic Substances and Disease Registry
(US) National Library of Medicine Toxicology Data Network
(US) National Toxicology Program
International Agency for Research on Cancer
RTECS (by subscription only)
Chemfinder
Inchem
Many larger businesses maintain their own product and chemical information.
There are also many subscription services available (CHEMINFO, OSH, CHEMpendium, Chem Alert, Chemwatch, Infosafe, RightAnswer.com's TOMES Plus, OSH Update, OSH-ROM, et cetera).
External links
(OSHA) passed standards on exposure to hexavalent chromium - Hexavalent Chromium National Emphasis Program
American Conference of Governmental Industrial Hygienists (ACGIH)
American Industrial Hygiene Association
Government of Hong Kong Occupational Safety and Health Council, Air Contaminants in the Workplace
View a PowerPoint Presentation Explaining What Industrial Hygiene Is - developed and made available by AIHA
The National Institute for Occupational Safety and Health Manual of Analytical Methods (NMAM)
UK Health and Safety Executive, Health and Safety Laboratory, Methods for the Determination of Hazardous Substances (MDHS)
International Organization for Standardization (ISO)
International Occupational Hygiene Association (IOHA)
Workplace Health Without Borders (WHWB)
Industrial hygiene
Occupational safety and health
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Internalizing disorder
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An internalizing disorder (or internalising disorder) is one type of emotional and behavioral disorder, along with externalizing disorders, and lower incidence disorders. People who have an internalizing disorder will keep their problems to themselves, or internalize the problems.
Signs and symptoms
Behaviors that are apparent in those with internalizing disorders include depression, withdrawal, anxiety, and loneliness. There are also behavioral characteristics involved with internalizing disorders. Some behavioral abnormalities include poor self-esteem, suicidal behaviors, decreased academic progress, and social withdrawal. Internalizing one's problems, like sadness, can cause the problems to grow into larger burdens such as social withdrawal, suicidal behaviors or thoughts, and other unexplained physical symptoms.
DSM-5
The internalizing disorders, with high levels of negative affectivity, include depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, trauma and stressor-related disorders, and dissociative disorders, bulimia, and anorexia come under this category, as do dysthymia, and somatic disorders (in Huberty 2017) and posttraumatic stress disorder (in Huberty 2004).
Treatment
Some treatments for internalizing disorders include antidepressants, electroconvulsive therapy, and psychotherapy.
See also
Deceit
Eating Disorders
Illegal drug abuse
Obsessive-compulsive disorders
References
Source
- Huberty 2004, 2017
External links
Depression at National Institute of Mental Health website
Types of mental disorders
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NANDA International
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NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA became NANDA International in response to the broadening scope of its membership. NANDA International published Nursing Diagnosis quarterly, which became the International Journal of Nursing Terminologies and Classifications, and then later was reconceptualized as the International Journal of Nursing Knowledge, which remains in print today. The Membership Network Groups foster collaboration among NANDA-I members in countries (Brazil, Colombia, Ecuador, México, Peru, Portugal, and Nigeria-Ghana) and for languages: the German Language Group (Germany, Austria, Switzerland) and the Dutch Language Group (Netherlands and Belgium).
History
In 1973, Kristine Gebbie and Mary Ann Lavin called the First National Conference on the Classification of Nursing Diagnoses (Gebbie & Lavin, 1975). It was held in St. Louis, Missouri. Attendees produced a beginning classification, an alphabetized list of nursing diagnoses. The conference also created three structures: A National Clearinghouse for Nursing Diagnoses, located at Saint Louis University and led by Ann Becker; a Nursing Diagnosis Newsletter, edited by Anne Perry; and a National Conference Group to standardize nursing terminology and led by Marjory Gordon. In 1982 NANDA was formed, and included members from the United States and Canada.
NANDA developed a nursing classification to organize nursing diagnoses into different categories. Although the taxonomy was revised to accommodate new diagnoses, in 1994 it became apparent that an overhaul was needed. In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns (Gordon, 1994), was released.
In 2002, NANDA became NANDA International in response to requests from its growing base of membership from outside North America. The acronym of NANDA was retained in the name because of the name recognition, but it is no longer merely "North American", and has members from 35 countries as of 2018.
Research and electronic health record utilization
Research has shown that NANDA-I is the most used, most researched of the standardized nursing languages (Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., ... & Wilkie, D. J., 2014). Their findings showed that the number of standardized nursing language (SNL) publications increased primarily since 2000, with most focusing on NANDA International, the Nursing Interventions Classification, and the Nursing Outcome Classification. The majority of the studies were descriptive, qualitative, or correlational designs that provide a strong base for understanding the validity and reliability of the concepts underlying the standardized nursing terminologies. There is evidence supporting the successful integration and use in electronic health records for two standardized nursing terminology sets: (1) the combination of NANDA International nursing diagnoses, Nursing Interventions Classification, and Nursing Outcome Classification; and (2) the Omaha System set.
Presidents
1982-1988 Dr. Marjory Gordon
1988-1993 Jane Lancour
1993-1997 Dr. Lois Hoskins
1997-2001 Dr. Judith Warren
2001-2005 Dr. Dorothy A. Jones
2005-2006 Dr. Kay Avant
2006-2007 Dr. Mary Ann Lavin
2007-2008 Dr. Martha Craft-Rosenberg
2008-2009 Dr. T. Heather Herdman
2009-2012 Dr. Jane Brokel
2012-2016 Prof. Dickon Weir-Hughes
2016-2020 Dr. Shigemi Kamitsuru
Taxonomy II
The current structure of NANDA's nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and Diagnoses (277) (Herdman, Kamitsuru, & Lopes, 2021).
See also
Nursing diagnoses (category)
Nursing diagnosis
Nursing process
References
Herdman, T.H. & Kamitsuru, S., Lopes, C.T. (Eds.) NANDA International nursing diagnoses: definitions and classification, 2021–24. NY: Thieme Medical Publishers.
Gebbie, KM & Lavin, MA (1975). Proceedings of the First National Conference on the Classification of Nursing Diagnoses. St. Louis: Mosby.
Gordon, M. (1994) Nursing Diagnosis: Process and Application, 3d Ed. St. Louis: Mosby
Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., ... & Wilkie, D. J. (2014). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review. International Journal of Nursing Studies, 51(8), 1160–1170.
External links
NANDA International's official website
Diagnosis codes
Nursing organizations in the United States
Organizations established in 1982
Nursing informatics
Nursing classification
1982 establishments in Missouri
Medical and health organizations based in Wisconsin
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Pervasive refusal syndrome
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Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized pediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognized mental disorder in the World Health Organization's current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Purported signs and symptoms
According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors) current psychiatric classification schemes, such as the Diagnostic and Statistical Manual of Mental Disorders, cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.
Hypothesized causes
Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.
Mechanism
Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.
Hypothesized epidemiology
Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7–15.
See also
Resignation syndrome
Asylum seekers with apathetic refugee children
References
Psychopathological syndromes
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Outpatient commitment
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Outpatient commitment—also called assisted outpatient treatment (AOT) or community treatment orders (CTO)—refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to an outpatient treatment plan designed to prevent further deterioration or recurrence that is harmful to themselves or others.
This form of involuntary treatment is distinct from involuntary commitment in that the individual subject to the order continues to live in their home community rather than being detained in hospital or incarcerated. The individual may be subject to rapid recall to hospital, including medication over objections, if the conditions of the order are broken, and the person's mental health deteriorates. This generally means taking psychiatric medication as directed and may also include attending appointments with a mental health professional, and sometimes even not to take non-prescribed illicit drugs and not associate with certain people or in certain places deemed to have been linked to a deterioration in mental health in that individual.
The criteria and process for outpatient commitment are established by law, which vary among nations and, in the U.S. and Canada, among states or provinces. Some jurisdictions require court hearings, where a judge will make a court order, and others require that treating psychiatrists comply with a set of requirements before compulsory treatment is instituted. When a court process is not required, there is usually a form of appeal to the courts or appeal to or scrutiny by tribunals set up for that purpose. Community treatment laws have generally followed the worldwide trend of community treatment. See mental health law for details of countries which do not have laws that regulate compulsory treatment.
Terminology
In the United States the term "assisted outpatient treatment" (AOT) is often used and refers to a process whereby a judge orders a qualifying person with symptoms of severe untreated mental illness to adhere to a mental health treatment plan while living in the community. The plan typically includes medication and may include other forms of treatment as well. Patients are often monitored and assigned to case managers or a community dedicated to treating mental health known as assertive community treatment (ACT).
Australia, Canada, England, and New Zealand use the term "community treatment order" (CTO).
Comparison to inpatient commitment
The terminology, "outpatient commitment", and legal construction often equate outpatient commitment with inpatient commitment but providing the patient more freedom. In practice, outpatient commitment may be used in situations where commitment would not be used because it is cheaper than inpatient commitment; seen as less draconian; and protects mental health professionals from moral, civil or criminal liability.
Preventive use
Outpatient commitment is used in some countries to prevent relapse of mental disorders, as many mental disorders are episodic in nature (for example bipolar disorder or schizophrenia) and it can be difficult to predict whether a mental disorder will reoccur. Some countries use outpatient commitment for first episode psychosis (FEP).
Implementation
Discussions of "outpatient commitment" began in the psychiatry community in the 1980s following deinstitutionalization, a trend that led to the widespread closure of public psychiatric hospitals and resulted in the discharge of large numbers of people with mental illness to the community.
Europe
Denmark
Denmark introduced outpatient commitment in 2010 with the Mental Health Act.
Germany
In Germany, CTOs were resumed in 2015 (formerly only for forensic psychiatry).
Laws regarding implementations are distincts between lander.
France
The CTOs are renewed every month. They were introduced under Nicolas Sarkozy presidency. Persons committed are registered on a national file accessible by police, even if they are not suspected of breaking the law.
The Netherlands
Dutch law provides for community treatment orders, and an individual who does not comply with the terms of their CTO may be subject to immediate involuntary commitment.
Norway
When Norway introduced outpatient commitment in the 1961 Mental Health Act, it could only be mandated for individuals who had previously been admitted for inpatient treatment. Revisions in 1999 and 2006 provided for outpatient commitment without previous inpatient treatment, but this provision is seldom used.
Sweden
In Sweden, the Compulsory Psychiatric Care Act provides for an administrative court to mandate psychiatric treatment to prevent harm to the individual or others. The law was created in 1991 and revised in 2008.
England and Wales
Changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. The Mental Health Act 2007 introduced community treatment orders (CTOs). CTOs are legally defined as a form of outpatient leave for individuals detained under section 3 of the Mental Health Act. As such, only members of the medical community are involved in issuing a CTO, though both the section 3 detention underlying the CTO and the CTO itself can be appealed to the Mental Health Tribunal where a panel consisting of medical doctors and a judge will make a decision.The legislation in the UK specifically allows CTOs to be issued after a single admission to hospital for treatment. However, the Royal College of Psychiatrists suggested limiting CTOs to patients with a history of noncompliance and hospitalization, when it reviewed the current mental health legislation.
John Mayer Chamberlain argues that this legislation was triggered by the Killing of Jonathan Zito by an individual who had interactions with mental health services prior this event, which led the then conservative government to argue for CTOs.
A review of patient data in London found that the average duration of a CTO in the UK was 3 years. Black people in the UK are more than ten times as likely to be under a CTO as white people. Concerns have been raised about the inability of Independent mental health advocates (IHMAs) to provide services to those under CTOs, since IMHAs cannot make contact with service users under CTOs and case workers could act as gatekeepers not providing referrals.
In a 2021 paper reviewing the mental health act, the UK government proposed a new form of indefinite outpatient commitment allowing for deprivation of liberties an continuous supervision termed supervised discharge. This discharge would be reviewed yearly, and only apply to individuals who would not benefit from treatment in a hospital setting and would be based on risk. Further, this legislation would only apply to restricted patients who have been diverted to the mental health care system from courts.
Scotland
Scotland has a different community commitment regime from England and Wales introduced in the 2003 Mental Health Act. There is ongoing debate in the UK on the place of coercion and compulsion in community mental health care.
Luxembourg
Patients may be recalled if they don't abide to conditions on residence or medical supervision decided by a psychiatrist on discharge for 3 months after having been released from an involuntary commitment.
North America
In the last decade of the 20th century and the first of the 21st, "outpatient commitment" laws were passed in a number of U.S. states and jurisdictions in Canada.
Canada
In the mid-1990s, Saskatchewan became the first Canadian province to implement community treatment orders, and Ontario followed in 2000. New Brunswick was the only province without legislation that provided for either CTOs or extended leave.
United States
44 U.S. states had enacted some version of an outpatient commitment law. In some cases, passage of the laws followed widely publicized tragedies, such as the murders of Laura Wilcox and Kendra Webdale.
Oceania
Australia and New Zealand introduced community treatment orders in the 1980s and 1990s.
Australia
In the Australian state of Victoria, community treatment orders last for a maximum of twelve months but can be renewed after review by a tribunal.
Controversy
Proponents have argued that outpatient commitment improves mental health, increases the effectiveness of treatment, lowers incidence of homelessness, arrest, incarceration and hospitalization and reduces costs. Opponents of outpatient commitment laws argue that they unnecessarily limit freedom, force people to ingest dangerous medications, impead on their human rights, or are applied with racial and socioeconomic biases.
Arguments for and proponents
While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate also make arguments based on the quality of life and cost associated with untreated mental illness and "revolving door patients" who experience a cycle of hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalizations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment. Proponents include: Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Justice, Agency for Healthcare Research and Quality (AHRQ), U. S Department of Health and Human Services, American Psychiatric Association, National Alliance on Mental Illness, International Association of Chiefs of Police. SAMHSA included Assisted Outpatient Treatment in their National Registry of Evidence Based Program and Practices. Crime Solutions: Management Strategies to Reduce Psychiatric Readmissions. The Treatment Advocacy Center are an advocacy group that campaign for the use of outpatient commitment.
A systematic review in 2016 that looked at around 200 papers investigating effectiveness of CTOs for patient outcomes. It found that non-randomized trials had dramatically varying results and found that no randomized controlled trials showed any benefits to the patient for outpatient commitment apart from a reduction in the risk of being the victim of crime.
The same interventions can have different effects in different countries due to legal, bureaucratic and social factors.
Cost
Research published in 2013 showed that Kendra's Law in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced arrests. About $125 million is also spent annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.
"Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized."
Arrests, danger, and violence
The National Institute of Justice considers assisted outpatient treatment an effective crime prevention program. Some studies in the US have found that AOT programs have reduced the chances of arrest. Kendra's Law has lowered risk of violent behaviors, reduced thoughts about suicide.
Outcomes and hospital admissions
AOT "programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior."
74% fewer participants experienced homelessness. 77% fewer experienced psychiatric hospitalization. 56% reduction in length of hospitalization. 83% fewer experienced arrest. 87% fewer experienced incarceration. 49% fewer abused alcohol. 48% fewer abused drugs. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that AOT helped them gain control over their lives. 81% said AOT helped them get and stay well. 90% said AOT made them more likely to keep appointments and take meds. 87% of participants said they were confident in their case manager's ability. 88% said they and their case manager agreed on what was important to work on.
In Nevada County, CA, AOT ("Laura's Law") decreased the number of psychiatric hospital days 46.7%, the number of incarceration days 65.1%, the number of homeless days 61.9%, and the number of emergency interventions 44.1%. Laura's Law implementation saved $1.81–$2.52 for every dollar spent, and receiving services under Laura's Law caused a "reduction in actual hospital costs of $213,300" and a "reduction in actual incarceration costs of $75,600."
In New Jersey, Kim Veith, director of clinical services at Ocean Mental Health Services, noted the AOT pilot program performed "beyond wildest dreams." AOT reduced hospitalizations, shortened inpatient stays, reduced crime and incarceration, stabilized housing, and reduced homelessness. Of clients who were homeless, 20% are now in supportive housing, 40% are in boarding homes, and 20% are living successfully with family members.
Writing in the British Journal of Psychiatry in 2013, Jorun Rugkåsa and John Dawson stated, "The current evidence from suggests that do not reduce readmission rates over 12 months."
"We find that New York State's AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients."
"The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes."
Effect on mental illness system
Access to services
In New York City net costs declined 50% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services.
Race
Service engagement
Consumers approve. Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT."
In Los Angeles, CA, the AOT pilot program reduced incarceration 78%, hospitalization 86%, hospitalization after discharge from the program 77%, and cut taxpayer costs 40%.
In North Carolina, AOT reduced the percentage of persons refusing medications to 30%, compared to 66% of patients not under AOT.
In Ohio, AOT increased attendance at outpatient psychiatric appointments from 5.7 to 13.0 per year. It increased attendance at day treatment sessions from 23 to 60 per year. "During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment."
In Arizona, "71% [of AOT patients] ... voluntarily maintained treatment contacts six months after their orders expired" compared with "almost no patients" who were not court-ordered to outpatient treatment.
In Iowa, "it appears as though outpatient commitment promotes treatment compliance in about 80% of patients... After commitment is terminated, about ¾ of that group remain in treatment on a voluntary basis."
Arguments against and opponents
Human rights advocate considers it a violation of freedom of thought or opinion, or views the use of neuroleptic as degrading treatment that can also impede on their right to work due to sometimes handicapping side effects. Other argue for a right of self-determination or self ownership, considering it a paternalistic approach that can be wrongly applied considering psychiatry criteria for diagnosis are very subjective backed by some studies questioning diagnosis (see Rosenhan experiment), the unlimited duration with often lack or no foresight to an end from the patient is also criticised.
Some opponents dispute the effects of compulsory treatment as positive, questioning the methodology of studies that show effectiveness. Some point to disparities in the way these laws are applied.
Opponents claim they are giving medication to the patient, but there are no brain chemical imbalances to correct in "mental illness". Our ability to control ourselves and reason comes from the mind, and the brain is being reduced in size from the psychiatric medications.
The slippery slope argument of "If government bodies are given power, they will use it in excess." was proven when 350–450 CTOs were expected to be issued in 2008 and more than five times that number were issued in the first few months. Every year there are increasing numbers of people subject to CTO's.
The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, akathisia, excessive weight gain leading to diabetes, addiction, sexual side effects, increased risk of suicide and QT prolongation. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders. The main opponents to any kind of coercion, including the outpatient commitment and any other form of involuntary commitment, are Giorgio Antonucci and Thomas Szasz.
See also
US specific:
Laura's Law
MindFreedom International
General:
Deinstitutionalisation
Psychiatric reform in Italy
Giorgio Antonucci
Notes
References
External links
Treatment Advocacy Center
Civil commitment laws and standards by state
MindFreedom
National Mental Health Consumers' Self-Help Clearinghouse
Mental Illness Policy Org
Kendra's Law
Laura's Law
Psychosis
Mental health law
Deinstitutionalisation
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Job characteristic theory
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Job characteristics theory is a theory of work design. It provides “a set of implementing principles for enriching jobs in organizational settings”. The original version of job characteristics theory proposed a model of five “core” job characteristics (i.e. skill variety, task identity, task significance, autonomy, and feedback) that affect five work-related outcomes (i.e. motivation, satisfaction, performance, and absenteeism and turnover) through three psychological states (i.e. experienced meaningfulness, experienced responsibility, and knowledge of results).
History
Work redesign first got its start in the 1960s. Up until then, the prevailing attitude was that jobs should be simplified in order to maximize production, however it was found that when subjected to highly routinized and repetitive tasks, the benefits of simplification sometimes disappeared due to worker dissatisfaction. It was proposed that jobs should be enriched in ways that boosted motivation, instead of just simplified to a string of repetitive tasks. It is from this viewpoint that Job Characteristics Theory emerged.
In 1975, Greg R. Oldham and J. Richard Hackman constructed the original version of the Job Characteristics Theory (JCT), which is based on earlier work by Turner and Lawrence and Hackman and Lawler. Turner and Lawrence, provided a foundation of objective characteristics of jobs in work design. Further, Hackman and Lawler indicated the direct effect of job characteristics on employee's work related attitudes and behaviors and, more importantly, the individual differences in need for development, which is called Growth Need Strength in Job Characteristics Theory.
In 1980, Hackman and Oldham presented the final form of the Job Characteristics Theory in their book Work Redesign. The main changes included the addition of two more moderators- Knowledge and Skill and Context Satisfaction, removal of the work outcomes of absenteeism and turnover, and increased focus on Internal Work Motivation. Several of the outcome variables were removed or renamed as well. Concentration was shifted to the affective outcomes following results from empirical studies that showed weak support for the relationship between the psychological states and behavioral outcomes.
In addition to the theory, Oldham and Hackman also created two instruments, the Job Diagnostic Survey (JDS) and the Job Rating Form (JRF), for assessing constructs of the theory. The JDS directly measures jobholders' perceptions of the five core job characteristics, their experienced psychological states, their Growth Need Strength, and outcomes. The JRF was designed to obtain the assessments from external observers, such as supervisors or researchers, of the core job characteristics.
Important variables
According to the final version of the theory, five core job characteristics should prompt three critical psychological states, which lead to many favorable personal and work outcomes. The moderators Growth Need Strength, Knowledge and Skill, and Context Satisfaction should moderate the links between the job characteristics and the psychological states, and the psychological states and the outcomes.
Core job characteristics
Skill Variety: The degree to which a job requires various activities, requiring the worker to develop a variety of skills and talents. Jobholders can experience more meaningfulness in jobs that require several different skills and abilities than when the jobs are elementary and routine.
Task Identity: The degree to which the job requires the jobholders to identify and complete a workpiece with a visible outcome. Workers experience more meaningfulness in a job when they are involved in the entire process rather than just being responsible for a part of the work.
Task Significance: The degree to which the job affects other people's lives. The influence can be either in the immediate organization or in the external environment. Employees feel more meaningfulness in a job that substantially improves either psychological or physical well-being of others than a job that has limited effect on anyone else.
Autonomy: The degree to which the job provides the employee with significant freedom, independence, and discretion to plan out the work and determine the procedures in the job. For jobs with a high level of autonomy, the outcomes of the work depend on the workers’ own efforts, initiatives, and decisions; rather than on the instructions from a manager or a manual of job procedures. In such cases, the jobholders experience greater personal responsibility for their own successes and failures at work.
Feedback: The degree to which the worker has knowledge of results. This is clear, specific, detailed, actionable information about the effectiveness of his or her job performance. When workers receive clear, actionable information about their work performance, they have better overall knowledge of the effect of their work activities, and what specific actions they need to take (if any) to improve their productivity.
Critical psychological states
Experienced Meaningfulness of the Work: The degree to which the jobholder experiences the work as intrinsically meaningful and can present his or her value to other people and/or the external environment.
Experienced Responsibility for Outcome of the Work: The degree to which the worker feels he or she is accountable and responsible for the results of the work.
Knowledge of Results of the Work Activities: The degree to which the jobholder knows how well he or she is performing.
Outcomes
Adopted from earlier work the personal and work outcomes of the initial theory were: Internal Work Motivation, Job Satisfaction, Absenteeism and Turnover, and Performance Quality. However, the 1980 revisions to the original model included removing absenteeism and turnover, and breaking performance into Quality of Work and Quantity of Work.
Moderators
Growth Need Strength (GNS): GNS is the strength of a person's need for personal accomplishment, learning, and development”. The theory posits that Growth Need Strength moderates both the relationship of core job characteristics and psychological states, and the relationship between psychological states and outcomes.
Knowledge and Skill: The level of knowledge and skill the worker possesses can moderate the relationship between the mediators and the job characteristics and outcomes. For motivating jobs, adequate knowledge and skill lead to experiencing the critical psychological states and better outcomes, while insufficient knowledge and skill discourage the psychological states and result in more negative outcomes. Unmotivating jobs don't allow the worker to experience the psychological states at all, thus knowledge and skill have no effect.
Context Satisfaction: The context of the job also affects employees’ experience. The authors suggest that when workers are satisfied with things like their managers, pay, co-workers, and job security they respond more positively to highly motivating jobs and less positively when they are not satisfied. The reason being that they must use attentional resources to handle the undesirable work context, which distracts from the richness otherwise inherent in the job.
Propositions
The three critical psychological states of job characteristic theory (JCT) draw upon cognitive motivation theory and some previous work on identifying the presence of certain psychological states could lead to favorable outcomes. JCT provided the chance to systematically assess the relationship between the previously discovered psychological states ('Experienced Meaningfulness, 'Experienced Responsibility, and Knowledge of Results) and outcomes. More importantly, previous work on work design showed job characteristics can predict individual performance, but did not provide “why” and “how” this relationship existed. Job Characteristics Theory filled this gap by building a bridge between job characteristics and work-related outcomes through the use of the three critical psychological states.
The three psychological states, which are also the conceptual core of the theory, include (1) Experienced Meaningfulness of the Work, (2) Experienced Responsibility for the Outcomes of the Work, and (3) Knowledge of the Results of Work Activities. These psychological states are theorized to mediate the relationship between job characteristics and work-related outcomes. According to the theory, these three critical psychological states are noncompensatory conditions, meaning jobholders have to experience all three critical psychological states to achieve the outcomes proposed in the model. For example, when workers experience the three psychological states, they feel good about themselves when they perform well. These positive feelings, in turn, reinforce the workers to keep performing well.
According to the theory, certain core job characteristics are responsible for each psychological state: skill variety, task identity, and task significance shape the experienced meaningfulness; autonomy affects experienced responsibility, and feedback contributes to the knowledge of results. Previous research found that four job characteristics (autonomy, variety, identity, and feedback) could increase workers’ performance, satisfaction, and attendance. Task significance was derived from Greg Oldham's own work experience as an assembly line worker. Though his job did not provide task variety or identity, he still experienced meaningfulness through the realization that others depended on his work. This realization led to the inclusion of task significance as another job characteristic that would influence experienced meaningfulness of the job. Thus, job characteristics theory proposed the five core job characteristics that could predict work related outcomes.
Motivating potential score
When a job has a high score on the five core characteristics, it is likely to generate three psychological states, which can lead to positive work outcomes, such as high internal work motivation, high satisfaction with the work, high quality work performance, and low absenteeism and turnover. This tendency for high levels of job characteristics to lead to positive outcomes can be formulated by the motivating potential score (MPS). Hackman and Oldham explained that the MPS is an index of the “degree to which a job has an overall high standing on the person's degree of motivation...and, therefore, is likely to prompt favorable personal and work outcomes”:
The motivating potential score (MPS) can be calculated, using the core dimensions discussed above, as follows:
Jobs that are high in motivating potential must be also high on at least one of the three factors that lead to experienced meaningfulness, and also must be high on both Autonomy and Feedback. If a job has a high MPS, the job characteristics model predicts that motivation, performance and job satisfaction will be positively affected and the likelihood of negative outcomes, such as absenteeism and turnover, will be reduced.
According to the equation above, a low standing on either autonomy or feedback will substantially compromise a job's MPS, because autonomy and feedback are the only job characteristics expected to foster experienced responsibility and knowledge of results, respectively. On the contrary, a low score on one of the three job characteristics that lead to experienced meaningfulness may not necessarily reduce a job's MPS, because a strong presence of one of those three attributes can offset the absence of the others.
Individual difference factor
In response to one of the disadvantages of Motivator–Hygiene Theory, Job Characteristics Theory added an individual difference factor into the model. While Herzberg et al. took into account the importance of intrinsically and extrinsically motivating job characteristics there was no consideration of individual differences. The importance of individual differences had been demonstrated by previous work showing that some individuals are more likely to positively respond to an enriched job environment than others. Thus, the original version of the theory posits an individual difference characteristic, Growth Need Strength (GNS), that moderates the effect of the core job characteristics on outcomes. Jobholders with high Growth Need Strength should respond more positively to the opportunities provided by jobs with high levels of the five core characteristics compared to low GNS jobholders.
Alternative theories of work design
Scientific management
Taylor's theory of scientific management emphasized efficiency and productivity through the simplification of tasks and division of labor.
Motivator–hygiene theory
Herzberg et al.’s Motivator–Hygiene Theory, aka Two-factor Theory, an influence on Job Characteristics Theory, sought to increase motivation and satisfaction through enriching jobs. The theory predicts changes in “motivators”, which are intrinsic to the work, (such as recognition, advancement, and achievement) will lead to higher levels of employee motivation and satisfaction; while “hygiene factors”, which are extrinsic to the work itself, (such as company policies and salary) can lead to lower levels of dissatisfaction, but will not actually effect satisfaction or motivation.
Sociotechnical systems theory
Sociotechnical systems theory predicts an increase in satisfaction and productivity through designing work that optimized person-technology interactions.
Quality improvement theory
Quality improvement theory is based on the idea that jobs can be improved through the analysis and optimized of work processes.
Adaptive structuration theory
Adaptive structuration theory provides a way to look at the interaction between technology's intended and actual use in an organization, and how it can influence different work-related outcomes.
Variations
Reverse scoring correction
Idaszak and Drasgow provided a corrected version of the Job Diagnostic Survey that corrected for one of the measurement errors in the instrument. It had been suggested that reverse scoring on several of the questions was to blame for the inconsistent studies looking at the factors involved in the Job Diagnostic Survey. Following a factor analysis, Idaszak and Drasgow found six factors rather than the theorized five characteristics proposed by the Job Characteristics Theory. Upon further investigation, they were able to show that the sixth factor was made up of the reverse coded items. The authors rephrased the questions, ran the analysis again, and found it removed the measurement error.
GN–GO model
Due to the inconsistent findings about the validity of Growth Need Strength as a moderator of the Job characteristic-outcomes relationship, Graen, Scandura, and Graen proposed the GN–GO model, which added Growth Opportunity as another moderator. They suggested there isn't a simple positive relationship between motivation and Growth Need Strength, but instead there is an underlying incremental (stairstep) relationship with various levels of Growth Opportunity. Growth Opportunity increments are described as “events that change either the characteristics of the job itself or the understanding of the job itself”. It was hypothesized that as people high in Growth Need Strength met each level of Growth Opportunity they could be motivated to increase their performance, but when people low on Growth Need Strength met these same increments their performance would either maintain or degrade. Field studies found more support for the GN–GO model than the original Growth Need Strength moderation.
Extension of characteristics and outcomes
Humphrey, Nahrgang, and Morgeson extended the original model by incorporating many different outcomes and job characteristics. The authors divided the revised set of Job Characteristics into three sections- Motivational, Social, and Work Context Characteristics; and the outcomes were portioned out into four parts- Behavioral, Attitudinal, Role Perception, and Well-being Outcomes. Results showed strong relationships between some of the expanded characteristics and outcomes, suggesting that there are more options for enriching jobs than the original theory would suggest.
Psychological ownership
Taking from earlier empirical research on Job Characteristics Theory and Psychological Ownership, researchers developed a model that combined the two theories. They replaced the psychological states of the Job Characteristics Theory with Psychological Ownership of the job as the mediator between job characteristics and outcomes. In addition to the positive personal and work outcomes of Job Characteristics Theory, negative outcomes (e.g. Territorial Behaviors, Resistance to Change, and Burden of Responsibility) were added.
Empirical tests
Since its inception, Job Characteristics Theory has been scrutinized extensively. The first empirical tests of the theory came from Hackman and Oldham themselves. The authors found the “internal consistency reliability of the scales and the discriminant validity of the items” to be “satisfactory”. They also tried to assess the objectivity of the measure by having the supervisors and the researchers evaluate the job in addition to the jobholders. More importantly, the authors reported the relationships predicted by the model were supported by their analysis.
Following these publications, over 200 empirical articles were published examining Job Characteristics Theory over the next decade. Fried and Ferris summarized the research on Job Characteristics Theory and found “modest support” overall. Fried and Ferris mentioned seven general areas of criticism in their review, which are discussed below:
Relation of objective and perceived job characteristics: Whether or not there is accuracy in the worker's perceptions of job characteristics is an important topic of concern for Job Characteristics Theory. Inaccurate ratings of the five job characteristics can be detrimental to the job enrichment process because the Job Diagnostic Survey, which is instrumental in determining what enrichment needs to take place, relies on jobholders' perceptions.
Influential forces on job perceptions: Social cues, personal factors, and what order the portions of the Job Diagnostic Survey is given can influence job perceptions. These “irrelevant cues” could color one's perception of the job characteristics.
Perceived versus objective job characteristics-outcomes relationships: Researchers have also been concerned about the objectivity of jobholders’ assessment of job characteristics and work outcomes, however studies have tended to show that this fear is largely unfounded.
Factors of the Job Diagnostic Survey: The support for the five dimensions of job characteristics in Job Characteristics Theory have mixed support among the studies examining the factor solutions of the Job Diagnostic Survey.
The job characteristics-outcomes relationships: Researchers have argued job characteristics have a stronger relationship with personal outcomes, than with work outcomes. More importantly, it was found that the Motivating Potential Score was not as predictive as adding up rater's assessment of the five job characteristics.
Mediator effects of critical psychological states: Researchers have found support for the mediating role of psychological states between job characteristics and personal outcomes, but didn't find similar evidence for the mediation on work outcomes.
Growth Need Strength's use as a moderator: There have been several studies investigating the validity of Growth Need Strength as a moderator. Many of the studies reported the moderating effect of Growth Need Strength to be low.
New developments
Over the years since Job Characteristics Theory's introduction into the organizational literature, there have been many changes to the field and to work itself. Oldham and Hackman suggest that the areas more fruitful for development in work design are social motivation, job crafting, and teams.
Social sources of motivation are becoming more important due to the changing nature of work in this country. More jobs are requiring higher levels of client-employee interaction, as well as increasing interdependence among employees. With this in mind, it would make sense to investigate the effect the social aspects have on affective and behavioral outcomes.
While Job Characteristics Theory was mainly focused on the organization's responsibility for manipulating job characteristics to enrich jobs there has been a considerable buzz in the literature regarding job crafting. In job crafting the employee has some control over their role in the organization. Hackman and Oldham point out there are many avenues of inquiry regarding job crafting such as: what are the benefits of job crafting, are the benefits due to the job crafting process itself or the actual changes made to the job, and what are the negative effects of job crafting?
Finally, they brought up the potential research directions relevant to team work design. Specifically, they discuss the need to understand when to use work-design aimed at the individual or team level in order to increase performance, and what type of team is best suited to particular tasks.
Practical implications
Job Characteristics Theory is firmly entrenched within the work design (also called job enrichment) literature, moreover the theory has become one of the most cited in all of the organizational behavior field. In practical terms, Job Characteristics Theory provides a framework for increasing employees’ motivation, satisfaction, and performance through enriching job characteristics.
Job Characteristics Theory has been embraced by researchers and used in a multitude of professions and organizations. In the applied domain, Hackman and Oldham have reported that a number of consulting firms have employed their model or modified it to meet their needs.
See also
Core self-evaluations
Industrial and organizational psychology
Job satisfaction
Motivation
Positive psychology in the workplace
Work design
Work motivation
References
Organizational theory
Organizational behavior
Industrial and organizational psychology
Motivational theories
Sociological theories
Psychological theories
Engineering management
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Conceptual schema
|
A conceptual schema or conceptual data model is a high-level description of informational needs underlying the design of a database. It typically includes only the core concepts and the main relationships among them. This is a high-level model with insufficient detail to build a complete, functional database. It describes the structure of the whole database for a group of users. The conceptual model is also known as the data model that can be used to describe the conceptual schema when a database system is implemented. It hides the internal details of physical storage and targets the description of entities, datatypes, relationships and constraints.
Overview
A conceptual schema is a map of concepts and their relationships used for databases. This describes the semantics of an organization and represents a series of assertions about its nature. Specifically, it describes the things of significance to an organization (entity classes), about which it is inclined to collect information, and their characteristics (attributes) and the associations between pairs of those things of significance (relationships).
Because a conceptual schema represents the semantics of an organization, and not a database design, it may exist on various levels of abstraction. The original ANSI four-schema architecture began with the set of external schemata that each represents one person's view of the world around him or her. These are consolidated into a single conceptual schema that is the superset of all of those external views. A data model can be as concrete as each person's perspective, but this tends to make it inflexible. If that person's world changes, the model must change. Conceptual data models take a more abstract perspective, identifying the fundamental things, of which the things an individual deals with are just examples.
The model does allow for what is called inheritance in object oriented terms. The set of instances of an entity class may be subdivided into entity classes in their own right. Thus, each instance of a sub-type entity class is also an instance of the entity class's super-type. Each instance of the super-type entity class, then is also an instance of one of the sub-type entity classes.
Super-type/sub-type relationships may be exclusive or not. A methodology may require that each instance of a super-type may only be an instance of one sub-type. Similarly, a super-type/sub-type relationship may be exhaustive or not. It is exhaustive if the methodology requires that each instance of a super-type must be an instance of a sub-type. A sub-type named "Other" is often necessary.
Example relationships
Each PERSON may be the vendor in one or more ORDERS.
Each ORDER must be from one and only one PERSON.
PERSON is a sub-type of PARTY. (Meaning that every instance of PERSON is also an instance of PARTY.)
Each EMPLOYEE may have a supervisor who is also an EMPLOYEE.
Data structure diagram
A data structure diagram (DSD) is a data model or diagram used to describe conceptual data models by providing graphical notations which document entities and their relationships, and the constraints that bind them.
See also
References
Further reading
Perez, Sandra K., & Anthony K. Sarris, eds. (1995) Technical Report for IRDS Conceptual Schema, Part 1: Conceptual Schema for IRDS, Part 2: Modeling Language Analysis, X3/TR-14:1995, American National Standards Institute, New York, NY.
Halpin T, Morgan T (2008) Information Modeling and Relational Databases, 2nd edn., San Francisco, CA: Morgan Kaufmann.
External links
A different point of view, as described by the agile community
Data modeling
Conceptual modelling
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Mental illness in ancient Greece
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Mental illness was an issue that many faced in ancient times much like in the modern world. In ancient Greece, many were divided over what they believed to be the cause of the illness that a patient faced. According to James Longrigg in his book Greek Medicine From the Heroic to the Hellenistic Age, many believed that mental illness was a direct response from the angry gods. According to Longrigg, the only way to fight this illness was to appease the gods. By doing so, it would ultimately rid the person of the demon that was ailing them. This led to many variations of treatment ranging from prayer to surgery to sacrifice. It is only through centuries of understanding as well as modern technology that we are now able to diagnose and treat those afflicted properly.
Treatment
Treatment of mental illness in ancient Greece was a new and experimental process due to the lack of modern-day tools and technology that allow doctors to identify these mental ailments. Some ancient physicians didn't understand what part of the body was responsible for the strange behavior and turned to prayer and forgiveness from the gods. However, most physicians understood mental illness was often caused by physical ailments such as an imbalance of the humors.
Hippocrates was a physician who believed that the brain was the center of thought, intelligence, and emotion. Because of this, he and many others came to the conclusion that mental disorders came from problems with the brain. As time went on and physicians began to better understand mental illness they began to treat patients in different ways. "They were mostly (not entirely) concerned with psychoses (externalizing disorders such as antisocial personality disorder and drug and alcohol use disorders) rather than neuroses (internalizing disorders such as depression and anxiety), and they took into account a full range of hard-to-define symptoms including inappropriate behavior in public, delusions, delirium, and hallucinations. Treatments also covered a whole range from physical restraint to counseling; they did not make much use of pharmaceuticals."
Role of religion and superstitions
Treatment of mental illness in ancient times was often linked to religion. Hippocrates was one of the leading faces when battling with mental illness, and it is mentioned in the textbook Religion and Philosophy: Belief and Knowledge in the Classical Age, his strong belief in the gods and the power they hold in being able to heal and help people. Doctors who were trained by Hippocrates were to take an oath that stated, "I swear by Apollo, the healer, Asklepios, Hygieis and Panacia, and I take witness all the gods, all the goddesses, to keep according to my ability and my judgement, the following oath and agreement.." Many times as a result of people's heavy religious beliefs and lack of knowledge, people who were stricken with madness were believed to be punished by the gods or possessed by demons. There are claims in the Old Testament of possession and madness cast upon people by god, these, in reality, may actually have been cases of mental illnesses that alter behavior such as schizophrenia, bipolar disorder or dissociative identity disorder. To people who had never encountered these diseases, it would have been difficult to diagnose and identify the disease in a logical way backed by hard evidence because there was likely no evidence to refer to. Due to this lack of evidence and logic, many treatments were designed to help clear the body of any spirits that may have taken over the patient’s body. “Archaeologists have unearthed skulls datable back to at least 5000 BCE which have been trephined or trepanned—small round holes have been bored in them with flint tools. The subject was probably thought to be possessed by devils which the holes would allow to escape.”
Mental illness in society
As in the modern age, there was a social stigma attached to those who were suffering from mental illness. "The ancient Greeks first gave voice to the concept of stigma noting that those who were marked with mental illness were often shunned, locked up, or on rare occasions put to death." People with diseases that altered behavior were often shunned and feared by those around them. This had to do with the fear of that which was not understood. Many thought the gods were angry at the affected individual and that they would receive a similar fate through association. The afflicted were also confined so that they would not cause injury to themselves, others, or damage to property. Plato once wrote “If a man is mad, he shall not be at large in the city, but his family shall keep him in any way they can.” In ancient Greece, it was up to the family of the ill to keep them in check as well as prevent them from disturbing the peace. Depending on the severity of the affliction, patients were either allowed to roam aimlessly through the city or forced to completely remain indoors.
Notes
Ancient Greece
Society of ancient Greece
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Psychiatric-mental health nurse practitioner
|
In the United States, a psychiatric-mental health nurse practitioner (PMHNP) is an advanced practice registered nurse trained to provide a wide range of mental health services to patients and families in a variety of settings. PMHNPs diagnose, conduct therapy, and prescribe medications for patients who have psychiatric disorders, medical organic brain disorders or substance abuse problems. They are licensed to provide emergency psychiatric services, psychosocial and physical assessments of their patients, treatment plans, and manage patient care. They may also serve as consultants or as educators for families and staff. The PMHNP has a focus on psychiatric diagnosis, including the differential diagnosis of medical disorders with psychiatric symptoms, and on medication treatment for psychiatric disorders.
A PMHNP is trained to practice autonomously. In 27 US states, nurse practitioners (NPs) already diagnose and treat without the supervision of a psychiatrist. This is in contrast to 2008, when nurse practitioners could autonomously diagnose and treat in 23 states, and could only prescribe in 12 states. In other states, PMHNPs have reduced or restricted practice, requiring a collaborative agreement with a physician expert, a standard scope of practice signed by a physician, or other limits on practice or prescribing. In these states, they still practice independently to diagnose disorders, provide therapy and prescribe medications. Titles vary by state, but usually NP, CRNP, APRN, or ARNP are commonly used.
Education
The first step to becoming a psychiatric-mental health nurse practitioner is becoming a registered nurse (RN). First, it is required to earn a Bachelor of Science in Nursing (BSN) from an accredited program (typically 4 years, or alternatively, an Associate Degree in Nursing (ADN) followed by a Bachelor of Science in Nursing Completion (BSN completion) program. After completing the program of choice, the National Council Licensure Examination for a Registered Nurse (NCLEX-RN) must be taken and passed before becoming an RN. After acquiring RN licensure, the individual can then start applying to a master's or doctoral program that is accredited by the Commission on Collegiate Nursing Education (CCNE), or the Accreditation Commission for Education in Nursing (ACEN). A Psychiatric Mental Health Nurse Practitioner degree requires two to five additional years of training. At minimum, the candidate must complete an approved Master of Science in Nursing (MSN), post-master's certificate, or Doctor of Nursing Practice (DNP) advanced nursing education program.
For individuals with a bachelor's degree in a field other than nursing, accelerated BSN programs or master's entry/graduate entry to practice nursing programs offer alternative pathways. Accelerated BSN programs provide a condensed curriculum for non-nurses to earn a BSN in one and a half to two years, allowing them to pursue MSN or DNP programs. Master's entry programs typically integrate basic nursing coursework with graduate-level PMHNP studies, taking three to four years to complete. All PMHNP programs require in clinical preceptorships, with a minimum of 500 hours for MSN and 1000 hours for DNP, before students become eligible for the PMHNP board examination.
The DNP degree has been suggested as the planned entry-level degree for advanced practice registered nurses, according to the ANCC. However, no state has initiated any laws regarding the DNP as the minimum degree. It is expected that current master's-prepared nurses will be "grandfathered' into the new system, and as long as they keep their certification current, they will not be required to pursue a doctoral degree.
There are many schools that offer the graduate education required for this profession. Notable schools with psychiatric-mental health nurse practitioner programs are Vanderbilt University School of Nursing, Yale School of Nursing, Saint Louis University, University of California-San Francisco, University of Pennsylvania, and Columbia University School of Nursing. A listing of PMHNP programs by state can be found online at the American Nurses Credentialing Center (ANCC) and American Psychiatric Nurses Association (APNA).
The cost of education can vary greatly. Programs at public universities are typically less expensive for state residents than for out-of-state residents. For example, at UCSF the cost for the Masters program with in-state tuition is approximately $12,245 a year; for an out-of-state student, the tuition is $24,798. In addition, programs at public universities tend to be less expensive than programs at private universities.
Characteristics
Psychiatric-mental health nurse practitioners require certain skills to excel in the field. Being a PMHNP requires compassion for their patients and their well-being, outstanding communication skills, and a pure dedication to helping their patients heal and improve their mental state. PMHNPs also need to easily form intimate connections with their patients and have high sensitivity towards their patients' emotions, thoughts, and feelings. Attentiveness is a very important characteristic because a PMHNP needs to be able to clearly and fully listen to what their patient is saying and what their report is showing. Along with attentiveness, a PMHNP should not make any assumptions, for it may tunnel their vision when it is crucial to have an open mind with different diagnoses that may be possible. An undervalued characteristic that is vital for a PMHNP to have is optimism. The PMHNP needs to stay optimistic because it will improve the relationship with the patient and the patient's attitude about improving their health. A characteristic that all PMHNPs must have is emotional stability. Times may get stressful, but staying composed for the health and safety of both the PMHNP and the patient is consequential. A PMHNP must possess these skills for their patients best interests as well as their own.
Practice Settings
Psychiatric-mental health nurse practitioners can choose between a variety of practice settings to work in. Some PMHNPs choose to specialize in a certain area within the field, which causes them to reside in certain practice settings. Another deciding factor for where a PMHNP chooses to reside may depend on whether they are following a specific psychiatrist to improve their education. Such settings include hospitals, detoxification clinics, outpatient offices, recovery centers, correctional facilities, court hospitals, private practices, or veterans affairs hospitals.
Sub-Specialties
Psychiatric-mental health nurse practitioners have many options as far as sub-specialties go. PMHNP's can specialize in specific areas within the field to work with a specific age of patients, a specific type of disorder, or specific conditions. Addiction medicine is a sub-specialty that deals with the diagnosis and treatment of individuals struggling with any type of addiction, whether it be drugs, nicotine, alcohol, prescription medicine, gambling, etc. The forensic psychiatry sub-specialty is the interconnection between mental health and criminology, where a PMHNP can anticipate dealing with individuals with mental illness in a court case or prison. The military sub-specialty deals with the diagnosis and treatment of many military-related mental health issues, such as PTSD. Child and adolescent psychiatry sub-specialty deals with diagnosing and treating many behavioral mental disorders found in children, such as ADHD. The geriatric psychiatry sub-specialty focuses on dealing with mental illness found in older adults in the late adulthood period. Psychosomatic medicine sub-specialty deals with the interconnections between mental illness and physical illness, such as self harm.
Disorders
Psychiatric-mental health nurse practitioners are able to assess, diagnose, treat, and improve a wide range of mental disorders. Common mental disorders PMHNP's work with are anxiety, depression, eating disorders, trauma-related disorders, personality disorders, and ADHD. Psychiatric-mental health nurse practitioners can work on a variety of mental disorders, and they can also work on a variety of age groups with these mental disorders. PMHNPs can work with any patient from early childhood to late adulthood.
Provider Shortages
Psychiatric-mental health nurse practitioners are in very high demand. As of 2020, throughout the United States, there were 5,766 areas with a psychiatric-mental health nurse practitioner shortage, and over 6,500 PMHNP's were needed to end this shortage. Throughout the United States, there has been a significant rise in mental health issues, and some are recently related to the COVID-19 pandemic. Throughout the pandemic, there were high reports of loneliness and financial instability that led to symptoms of depression and anxiety. Due to this rise in mental illness throughout the United States, psychiatric-mental health practitioners are in need now more than ever.
Even before the COVID-19 pandemic, there were already rising numbers of mental health issues seen in adults and youth in the United States. Prior to COVID-19, 19.6% of adults experienced a mental illness, and that estimates around 50 million American adults. Along with an increase in mental health issues, the rate of suicide ideation among adults has been rising, and it especially peaked during the COVID-19 pandemic. Depressive episodes, severe depression, and suicide rates increased among youth in the United States. Suicide is now the second-leading cause of death among adolescents in the United States. The rate of substance abuse by American adults and adolescents has also been increasing.
With the rise of mental health issues found in adults and youth in the United States, PMHNPs are eagerly needed. Most adults and youth who deal with mental issues do not seek help, and this is particularly because it takes weeks, or even months, before individuals can be seen by a PMHNP. There is a huge labor shortage of PMHNPs that needs to be filled now because of the drastic increase in mental health issues in the United States.
Salary
The salary of a PMHNP is much higher than the salary of an RN with just a BSN degree. The average median salary of a PMHNP in the United States as of 2019 was $111,840. The average hourly rate of a PMHNP in the United States as of 2019 was $53.77. The state and practice setting in which a PMHNP works, as well as the number of years of experience, will determine how much a PMHNP should expect to make annually. The annual salary of a PMHNP changes depending on the state of residence with California having the highest annual salary at $149,070 and Tennessee has the lowest annual salary at $96,510. The annual salary of a PMHNP also differs depending on the practice setting one resides in. The average annual salary of a PMHNP working in a medical hospital is $115,790. The average annual salary of a PMHNP working in an outpatient center is $119,920. The average annual salary of a PMHNP working in a physician's office is $108,930. The average annual salary of a PMHNP working in a health practitioner office is $108,660. The average annual salary of a PMHNP working at a college or university is $105,310. The years of experience a PMHNP has will also be taken into consideration with their annual salary. A PMHNP with less than a year of experience should expect to make, on average, $103,000 annually. A PMHNP with one to four years of experience should expect to make, on average, $109,000 annually. A PMHNP with five to nine years of experience should expect to make, on average, $114,000 annually. A PMHNP with ten to nineteen years of experience should expect to make on average $120,000 annually.
See also
Psychiatric and mental health nursing
List of counseling topics
Mental health professional
Mental health
Mental illness
Nurse Practitioner
References
Mental health occupations
Counseling
Psychiatric nursing
Advanced practice registered nursing
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Psychasthenia
|
Psychasthenia was a psychological disorder characterized by phobias, obsessions, compulsions, or excessive anxiety. The term is no longer in psychiatric diagnostic use, although it still forms one of the ten clinical subscales of the popular self-report personality inventories MMPI and MMPI-2. It is also one of the fifteen scales of the Karolinska Scales of Personality.
MMPI
The MMPI subscale 7 describes psychasthenia as akin to obsessive-compulsive disorder, and as characterised by excessive doubts, compulsions, obsessions, and unreasonable fears. The psychasthenic has an inability to resist specific actions or thoughts, regardless of their maladaptive nature. In addition to obsessive-compulsive features, the scale taps abnormal fears, self-criticism, difficulties in concentration, and guilt feelings. The scale assesses long-term (trait) anxiety, although it is somewhat responsive to situational stress as well.
The psychasthenic has insufficient control over their conscious thinking and memory, sometimes wandering aimlessly and/or forgetting what they were doing. Thoughts can be scattered and take significant effort to organize, often resulting in sentences that do not come out as intended, therefore making little sense to others. The constant mental effort and characteristic insomnia induces fatigue, which worsens the condition. Symptoms can possibly be greatly reduced with concentration exercises and therapy, depending on whether the condition is psychological or biological.
Earlier conceptions
The term "psychasthenia" was first primarily associated with French psychiatrist Pierre Janet, who divided the neuroses into the psychasthenias and the hysterias. (He discarded the then common term "neurasthenia" (weak nerves) since it implied a neurological theory where none existed.) Whereas the hysterias involved at their source a narrowing of the field of consciousness, the psychasthenias involved at root a disturbance in the fonction du reél ('function of reality'), a kind of weakness in the ability to attend to, adjust to, and synthesise one's changing experience (cf. executive functions in today's empiricist psychologies). Swiss psychiatrist Carl Jung later made Janet's hysteric and psychasthenic types the prototypes of his extroverted and introverted personalities.
The German-Swiss psychiatrist Karl Jaspers, following Janet, described psychasthenia as a variety of phenomena "held together by the theoretical concept of a 'diminution of psychic energy'." The psychasthenic person prefers to "withdraw from his fellows and not be exposed to situations in which his abnormally strong 'complexes' rob him of presence of mind, memory and poise." The psychasthenic lacks confidence, is prone to obsessional thoughts, unfounded fears, self-scrutiny and indecision. This state in turn promotes withdrawal from the world and daydreaming, yet this only makes things worse. "The psyche generally lacks an ability to integrate its life or to work through and manage its various experiences; it fails to build up its personality and make any steady development." Jaspers believed that some of Janet's more extreme cases of psychasthenia were cases of schizophrenia. Jaspers differentiates and contrasts psychasthenia with neurasthenia, defining the later in terms of "irritable weakness" and describing phenomena such as irritability, sensitivity, a painful sensibility, abnormal responsiveness to stimuli, bodily pains, strong experience of fatigue, etc.
References
External links
Stress-related disorders
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Social medicine
|
Social medicine is an interdisciplinary field that focuses on the profound interplay between socio-economic factors and individual health outcomes. Rooted in the challenges of the Industrial Revolution, it seeks to:
Understand how specific social, economic, and environmental conditions directly impact health, disease, and the delivery of medical care.
Promote conditions and interventions that address these determinants, aiming for a healthier and more equitable society.
Social medicine as a scientific field gradually began in the early 19th century, the Industrial Revolution and the subsequent increase in poverty and disease among workers raised concerns about the effect of social processes on the health of the poor. The field of social medicine is most commonly addressed today by efforts to understand what are known as social determinants of health.
Scope
The major emphasis on biomedical science in medical education, health care, and medical research has resulted into a gap with our understanding and acknowledgement of far more important social determinants of health and individual disease: social-economic inequalities, war, illiteracy, detrimental life-styles (smoking, obesity), discrimination because of race, gender and religion. Farmer et al. (2006) gave the following explanation for this gap:
The holy grail of modern medicine remains the search for a molecular basis of disease. While the practical yield of such circumscribed inquiry has been enormous, exclusive focus on molecular-level phenomena has contributed to the increasing "desocialization" of scientific inquiry: a tendency to ask only biological questions about what are in fact biosocial phenomena.
They further concluded that "Biosocial understandings of medical phenomena are urgently needed".
Social medicine is a vast and evolving field, and its scope can cover a wide range of topics that touch on the intersection of society and health. The scope of social medicine includes:
Social Determinants of Health: Investigation of how factors like income, education, employment, race, gender, housing, and social support impact health outcomes.
Health Equity and Disparities: Studying the disparities in health outcomes among different groups based on racial, economic, gender, or other sociodemographic factors and creating strategies to promote equal health opportunities for all.
Health Systems and Policies: Evaluating how different healthcare systems, structures, and policies impact health outcomes. This includes assessing the effectiveness of public health campaigns, insurance models, and health-related legislation.
Environmental Health: Understanding how environmental factors such as pollution, climate change, and access to clean water and sanitation affect health.
Global Health: Addressing health concerns that transcend national borders, such as epidemics, pandemics, or the health impacts of globalization.
Cultural Competency: Training healthcare professionals to understand and respect cultural differences in patient care. This involves understanding diverse health beliefs, values, and behaviors.
Migration and Health: Studying the health implications of migration, whether it's due to conflict, economic reasons, or other factors. This includes looking at issues like refugee health, healthcare access for undocumented migrants, and more.
Urbanization and Health: Analyzing the impact of urban living conditions, urban development, and city policies on health.
Mental Health: Delving into how social factors like stigma, discrimination, social isolation, and traumatic events impact mental health and well-being.
Violence and Health: Investigating the health implications of different forms of violence, including domestic violence, community violence, and structural violence, and developing strategies to prevent and address these impacts.
Occupational Health: Examining the health impacts of different work environments, job roles, and organizational structures.
Substance Use and Addiction: Analyzing the social determinants and implications of substance use, including policies and societal attitudes toward different substances.
Community Engagement and Empowerment: Working with communities to identify their health needs, co-create interventions, and mobilize resources to promote health.
Medical Education: Integrating social medicine topics into medical curricula to ensure that healthcare professionals are equipped to address the social aspects of health and illness.
Interdisciplinary Collaboration: Working with professionals from diverse fields, such as anthropology, sociology, economics, and urban planning, to address complex health challenges.
Comparison with Public Health
While there is some overlap between social medicine and public health , there are distinctions between the two fields. Distinct from public health, which concentrates on the health of entire populations and encompasses broad strategies for disease prevention and health promotion, social medicine dives deeper into the societal structures and conditions that lead to health disparities among different groups. Its approach is often more qualitative, honing in on the lived experiences of individuals within their social contexts. While public health might launch broad-spectrum interventions like vaccination campaigns or sanitation drives, social medicine probes the underlying socio-economic reasons why certain communities might be disproportionately affected by health challenges. The ultimate goal of social medicine is to ensure that societal structures support the health of all members, particularly those most vulnerable or marginalized.
Social Medicine:
Focus: Primarily on the socio-economic factors that affect health and how these can be addressed to promote better health outcomes.
Approach: It delves deeper into the relationship between society and individual health. This includes the impacts of discrimination, inequality, poverty, and other social determinants.
Historical Context: Originated during the Industrial Revolution as a response to the health challenges faced by the working class due to industrialization.
Goal: To use the understanding of socio-economic factors to influence healthcare practices and policy to bring about a healthier society.
Public Health:
Focus: On the health of the general population, aiming to prevent disease and promote health at a community or population level.
Approach: It encompasses a broader set of tools and strategies, ranging from disease surveillance, health education, policy recommendations, and health promotion initiatives.
Historical Context: Has its roots in controlling infectious diseases, ensuring clean water and sanitation, and other community-wide health initiatives.
Goal: To improve health outcomes through community interventions, policy, and education, often utilizing epidemiological studies and data analysis.
To visualize the difference: Imagine a city facing an outbreak of a disease. A public health approach might involve vaccination campaigns, public health advisories, and quarantine measures. A social medicine approach might delve into why certain communities within the city are more affected than others, looking at housing conditions, employment status, racial or socio-economic discrimination, and other societal factors, and then proposing solutions based on these insights.
Both fields recognize the importance of the social determinants of health but approach the topic from slightly different angles and with varying emphases. In practice, there's a lot of collaboration and overlap between social medicine and public health, as both are essential for a holistic approach to health and wellness.
Social care
Social care aims to promote wellness and emphasizes preventive, ameliorative, and maintenance efforts during illness, impairment, or disability. It adopts a holistic perspective on health and encompasses a variety of practices and viewpoints aimed at disease prevention and reduction of the economic, social, and psychological burdens associated with prolonged illnesses and diseases. The social model was developed as a direct response to the medical model, the social model sees barriers (physical, attitudinal and behavioural) not just as a biomedical issue, but as caused in part by the society we live in – as a product of the physical, organizational and social worlds that lead to discrimination (Oliver 1996; French 1993; Oliver and Barnes 1993). Social care advocates equality of opportunities for vulnerable sections of society.
History
German physician Rudolf Virchow (1821–1902) laid foundations for this model. Other prominent figures in the history of social medicine, beginning from the 20th century, include Salvador Allende, Henry E. Sigerist, Thomas McKeown, Victor W. Sidel, Howard Waitzkin, and more recently Paul Farmer and Jim Yong Kim.
In The Second Sickness, Waitzkin traces the history of social medicine from Engels, through Virchow and Allende. Waitzkin has sought to educate North Americans about the contributions of Latin American Social Medicine.
In 1976, the British public health scientist and health care critic Thomas McKeown, MD, published "The role of medicine: Dream, mirage or nemesis?", wherein he summarized facts and arguments that supported what became known as McKeown's thesis, i.e. that the growth of population can be attributed to a decline in mortality from infectious diseases, primarily thanks to better nutrition, later also to better hygiene, and only marginally and late to medical interventions such as antibiotics and vaccines. McKeown was heavily criticized for his controversial ideas, but is nowadays remembered as "the founder of social medicine".
Occupational Health & Social Medicine
The world of work played a fundamental role in the development of a social approach to health during the first industrial revolution, as exemplified by Virchow’s work on typhus and coal miners. Over the past 50 years, Occupational Safety and Health. The resulting distinction between work/nonwork related risks and outcomes has served as an artificial line of demarcation between OSH and the rest of public health. However, growing social inequality, the fundamental reorganization of the world of work, and a broadening of our understanding of the relationship between work and health have blurred this line of demarcation and highlight the need to expand and complement the reductionist view of cause and effect. In response, OSH is reintegrating a social approach to account for the social, political, and economic interactions that contribute to occupational health outcomes.
See also
Epidemiology
Medical anthropology
Medical sociology
Social determinants of health in poverty
Social epidemiology
Social psychology
Socialized medicine
Society for Social Medicine
References
Bibliography
Social Medicine: http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/index
Social Medicine Portal: http://www.socialmedicine.org/
Matthew R. Anderson, Lanny Smith, and Victor W. Sidel. What is Social Medicine? Monthly Review: 56(8). http://www.monthlyreview.org/0105anderson.htm
King NMP, Strauss RP, Churchill LR, Estroff SE, Henderson GE, et al. editors (2005) Patients, doctors, and illness. Volume I: The social medicine reader 2nd edition Durham: Duke University Press.
Henderson GE, Estroff SE, Churchill LR, King NMP, Oberlander J, et al. editors (2005) Social and cultural contributions to health, difference, and inequality. Volume II: The social medicine reader 2nd edition Durham: Duke University Press.
Oberlander J, Churchill LR, Estroff SE, Henderson GE, King NMP, et al. editors (2005) Health policy, markets, and medicine. Volume III: The social medicine reader 2nd edition Durham: Duke University Press.
External links
Introduction to the journal: Social Medicine
What is social medicine?
Anthropology
Determinants of health
Medical terminology
History of medicine
Medical sociology
Public health
Social philosophy
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Reversal theory
|
Reversal theory is a structural, phenomenological theory of personality, motivation, and emotion in the field of psychology. It focuses on the dynamic qualities of normal human experience to describe how a person regularly reverses between psychological states, reflecting their motivational style, the meaning they attach to a situation at a given time, and the emotions they experience.
Introduction
Unlike many theories related to personality, reversal theory does not consist of static traits (trait theory), but rather a set of dynamic motivational states. As people cycle through states, they will see different things as important, experience different emotions, react differently, and look for quite different rewards. Motivation drives orientation, styles, perspective, and desires. The theory emphasizes the changeability of human nature.
Hundreds of empirical papers have been published testing, or using, one or another idea from the theory. It has also generated over twenty books, many standardized questionnaires, its own journal, and various training techniques used in a number of countries. Workshops have been developed for self-development, leadership, creativity, and salesmanship among other topics. Other previous and current applications of the theory include risk-taking, violence, creativity, humor, sexual behavior, ritual, terrorism, advertising, fantasy, and so on.
The Reversal Theory Society has its own journal, the Journal of Motivation, Emotion, and Personality. A number of instruments have been created to measure reversal theory phenomena. Many of these focus on state dominance – which states are more prevalent for a person over time. While others attempt to capture the phenomena of the reversals themselves – how people's states shift in specific situations.
Origins
Reversal theory was initially developed primarily by British psychologist Dr. Michael Apter and psychiatrist Dr. Ken Smith in the mid-1970s. The starting point was Smith's recognition of a personality dimension which he believed had been largely overlooked but was of critical importance in understanding certain kinds of pathology. He coined the terms 'telic' and 'paratelic' to describe the endpoints of this dimension, which could be described in less precise language as the dimension of serious to playful. Apter made a fundamental change to this idea by suggesting that we were not dealing here with enduring traits but with passing states.
Apter's suggestion was that in everyday life people moved backward and forward between two opposite states, which were alternative ways of seeing the world. The dimension was really a dichotomy. In the normal way of things, people were playful and serious in turn. (Such alternations are widespread in all kinds of different systems in the real world and known in cybernetics as 'bistable states'. Examples would be teeter-totters (seesaws), toggle switches, and Gestalt reversal figures.) In emphasizing this kind of dynamic, they would be challenging the emphasis placed in personality theory on enduring traits. To them, people were more like waves than the rocks that they broke on.
Conceptual framework
States
The theory distinctively proposes that human experience is structurally organized into metamotivational domains, of which four have been identified. Each domain consists of a pair of opposing values or motives so that only one of each pair can be experienced in any given moment. Each pair in a domain represents two opposite forms of motivation – only one state in each pair can be active at a time. Humans reverse between the states in each pair depending on a number of factors, including our inherent tendency to adopt one style over the other.
Serious/Playful (Telic/Paratelic)
Conforming/Rebellious
The first four motivational states are referred to as the somatic pairs. This is due to the significance of their interaction, e.g. Serious-rebelliousness (organizing a protest march) is noticeably different from playful rebelliousness (telling a joke in a business meeting).
Mastery/Sympathy
Self/Other (Autic/Alloic)
The last four motivational states are referred to as the transactional pairs. This is due to the significance of their interaction, e.g. self-mastery (running a marathon) is noticeably different from others-mastery (training someone to run a marathon).
Reversals
The primary emphasis of reversal theory lies in the concept of reversals – by "triggering" a reversal between states, we can change the meaning attributed to the situation. E.g., what seemed serious before, can suddenly feel exciting with the right change in situation or mindset. Reversals can be created by changing a situation, reframing it, role-playing, or using specific symbols or props that invoke a specific state (e.g., a toy can help trigger the Playful state; the image of a traffic sign may invoke the Conforming state).
Reversals can occur as a result of frustration, or by the passing of time (called satiation).
Reversal theory links the motivational states above to emotion by proposing that if one is in a state and things are going well, positive emotions result; if the needs of the state are not fulfilled, negative emotions result.
Synergy
Cognitive synergy is what happens when one experiences opposite qualities attached to the same thing at the same time. Examples would include works of art, metaphors, jokes, toys, and so on. Thus, a representational painting is both a three-dimensional scene and a flat canvas with paint on it. Being aware of both these aspects is what gives it a special synergic quality in experience. But reversal theory offers an interesting perspective on the phenomenon: When perceived in the serious (telic) state synergies tend to be a nuisance, while in the playful (paratelic) state they are usually intriguing and fun.
Bistability
This the basis for the principle of homeostasis that is found in many fields of study, including many theories found in psychology. Figure 1 (above) demonstrates this principle. The idea that humans are always looking for a perfect medium state of arousal and anything too extreme in either direction is not to be desired, i.e., boredom or anxiety.
Reversal theory proposes an altogether different view of arousal, which is what is called bistability. Bistability emphasizes polarity in the hedonic tone, and this is represented by the curves of the "butterfly curves" figure. It demonstrates that arousal is experienced in each state in a different – indeed opposite way and has its own unique range of emotions. In the serious (telic) state, represented by the solid curve, this range is from relaxation to anxiety, and in the playful paratelic) state, represented by the dashed curve, from boredom to excitement.
In the serious state, one becomes anxious as threatening or demanding events raise arousal levels, but pleasantly relaxed when a task is completed. In the paratelic state, one becomes pleasantly excited as one becomes more emotionally involved and aroused, but bored if there is a lack of stimulation. It will be seen from this that reversal theory gives a very different interpretation of arousal from optimal arousal theory, with its famous inverted u-curve. This enables it, among other things, to make sense of the fact that some activities involve very high arousal and intense pleasure (sexual behavior, for example, and playing or watching a sport) – something which optimal arousal theory has no satisfactory way of dealing with. It also introduces a certain dynamic into the situation through the possibility of sudden changes in experience, and it will have been noticed that as arousal gets higher or lower, so the effect of reversal from one curve to the other becomes more dramatic.
The world is seen differently – there is a different experiential structure in each case. One aspect of this is what reversal theory calls 'the protective frame'. This reversal within arousal explains such phenomena as why people indulge in dangerous sports, why people commit recreational violence, the nature of sexual perversion and sexual dysfunction, the attraction of military combat, and the nature of post-traumatic stress disorder. For example, people gratuitously confront themselves with risk in dangerous sports like parachuting and rock-climbing, in order to achieve high (not moderate) arousal. This high arousal may be experienced as anxiety, but if the danger is overcome (and thereby a protective frame set up), then there will be a switch to the playful (in the moment) curve, and this will result in excitement as intense as the anxiety had been – and hopefully longer-lasting.
Dominance
Reversal theory introduced the term dominance to make the motivational styles a testable factor in psychometrics, so as to expand its application regions. Dominance means the tendency that an individual has to be one kind of person or another over time. An individual may reverse into a Playful (paretelic) state, but if he or she is Serious (telic) dominant, he or she will easily reverse into Serious states. This term distinguished the reversal theory from the traditional trait theory, namely, one's personality is not a permanent asset but a reversing tendency changing in accordance to the environment, etc.
Parapathic emotions and the protective frame
All high arousal emotions will be experienced pleasantly in the form of excitement when the individual is in the paratelic state – even the most otherwise unpleasant emotions. Such paradoxical emotions are referred to in the theory as 'parapathic emotions'. So it is possible to have, for example, parapathic anxiety, as in riding a roller coaster. Parapathic emotions arise when the ongoing experience involves what the theory calls a 'protective frame'. Sometimes this makes negative emotions enjoyable, like fear in a horror movie, but this can also make psychologically difficult situations bearable. The frame can be imagined as an emotional safety bubble. Sometimes this frame, which can be physical or psychological, may serve as what can be imagined an emotional safety bubble.
Psychodiversity
Humans are complex and act in accordance with many, even contradictory values. The needs they produce may vary, but any attempt to structure them (linear, hierarchical, etc.) is left wanting. The normally-functioning person, then, is able to access all the states at different times, and, over time, obtain all the different satisfactions that are available in these various states. Such a well-rounded person may be said to display psychodiversity.
The term can be understood by analogy with the biological concept of biodiversity. A biodiverse ecology is one that contains many different species. It is healthy in that, if the climate changes, at least some species will survive to start rebuilding the ecology. Likewise, a person who displays psychodiversity is able to survive personal problems and thrive in different and changing environments.
Scientific application
Reversal theory has attracted widespread interest among the research community, especially of psychologists, and more than 500 papers and book chapters have been written, along with almost 30 books. There have been some 70 graduate dissertations, mainly doctoral.
The theory has been used in the elucidation of a wide diversity of topics and one of the main strengths of the theory is its comprehensiveness and potential for integration. Here, in no special order, are some of the topics that have been worked on:
Stress, addiction, anxiety, depression, delinquency, hooliganism, personality disorder, boredom, gambling, crime, violence, leadership, teamwork, creativity, risk-taking, teaching, dieting, humor, aesthetics, play, sport, exercise, design, advertising, corporate culture, consumer behavior, hotel management, sexual behavior, religious faith, ritual, spying, and marital relations.
Practical application
Sport psychology
Following the publication of John Kerr's Counseling Athletes: Applying Reversal Theory, reversal theory has started to be recognized as a useful approach to training, exercise, and sport, although it is difficult to know how many athletes and coaches are actually using it. Kerr and others have reported it being used in a variety of sports, including soccer, figure skating, golf, and martial arts. Graham Winter, a coach for three Australian Olympic teams, utilizes reversal theory for the psychological health of his athletes.
Future
The recent rise in interest in personal measurement ("the measured self"), advances in the technology enabling/supporting personal measurement (e.g., smartphones, wearable technology), and developments in modeling and analyzing repeatedly-measured experiences (i.e., ecological momentary assessment, experience sampling, and multilevel modeling) the idea (reversals and the theory) provides a framework and sets of hypotheses regarding change over time. At present, such measurement is at the descriptive stage, and the application of reversal theory can move this body of work toward more predictive science.
Biological and medical researchers have begun to develop instrumentation that allows the tracking of physiological variables in real-time from individual subjects in their natural settings. Psychologists are beginning to look at the possibilities opened up to them by this technology, and reversal theory is perfectly positioned to take advantage of it. For example, using the recent "Reversal Theory State Measure" to study the causes of reversals, the relative frequency of reversal in different people ('reversibility'), the biases among the eight states in different people, and so on. There are many ongoing areas of application for this such as telehealth.
Instrumentation
Since the formulation of reversal theory, dozens of psychometric instruments have been developed to test the motivational styles. An early instrument was The Telic Dominance Scale (TDS) developed by Murgatroyd, Rushton, Apter & Ray in 1978. This scale was aimed primarily at assessing Telic Dominance.
The Apter Motivational Style Inventory (AMSP) is a research instrument that assesses dominant styles. A commercial version is used for training and development by practitioners educated by Apter Solutions.
Others include the Apter Leadership Profile [System] (ALPS), which utilizes a 360-degree measurement of leaders' motivational micro-climates, and how they interact with their direct reports. The Reversal Theory State Measure (RTSM), a more recently developed tool system, utilizes technology to measure ongoing motivational state changes over time.
Society, journal, and conference
A society for researchers and practitioners in reversal theory was set up in 1983. The society has organized regular biennial conferences since then. In 2013, an open-access journal was launched: Journal of Motivation, Emotion and Personality: Reversal Theory Studies.
The Reversal Theory Society's presidents have been:
1983-1985 Stephen Murgatroyd
1985-1987 Michael Cowles
1987-1989 John Kerr
1989-1991 Stephen Murgatroyd
1991-1993 Kathleen O'Connell
1993-1995 Sven Svebak
1995-1997 Ken Heskin
1997-1999 Mark McDermott and Murray Griffin
1999-2001 Kathy LaFreniere
2001-2003 George V. Wilson
2003-2005 Richard Mallows
2005-2007 Koenraad Lindner
2007-2009 Joanne Hudson
2009-2011 Tony Young
2011-2013 Jennifer Tucker
2013-2015 Fabien D. Legrand
2015-2017 Kenneth M. Kramer
2017-2019 Joanne Hudson
2019-2021 Jay Lee
2021-2023 Nathalie Duriez
References
Further reading
Apter, M.J. (Ed.) (2001) Motivational Styles in Everyday Life: A Guide to Reversal Theory. Washington, D.C.: American Psychological Association.
Apter, M.J. (2007) Reversal Theory: The Dynamics of Motivation, Emotion and Personality, 2nd. Edition. Oxford: Oneworld Publications.
Apter, M.J. (2018) Zigzag: Reversal and Paradox in Human Personality, Matador.
Apter, M.J. (2007) Danger: Our Quest for Excitement. Oxford: Oneworld Publications.
Carter, S. and Kourdi, J. (2003) The Road to Audacity: Being Adventurous in Life and Work. Palgrave Macmillan.
Kerr, J.H. (2004). Rethinking aggression and violence in sport. London: Routledge.
Kerr, J.H. (2001). Counseling Athletes: Applying Reversal Theory. London: Routledge.
Kerr, J.H., Lindner, K.H. and Blaydon (2007). Exercise Dependence. London: Routledge.
Mallows, D. (2007) Switch to Better Behaviour Management: Reversal Theory in Practice. Peter Francis Publishers.
Rutledge, H. & Tucker, J. (2007) Reversing Forward: A Practical Guide to Reversal Theory, Fairfax, Virginia: OKA (Otto Kroeger Associates).
Psychological theories
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Self-diagnosis
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Self-diagnosis is the process of diagnosing, or identifying, medical conditions in oneself. It may be assisted by medical dictionaries, books, resources on the Internet, past personal experiences, or recognizing symptoms or medical signs of a condition that a family member previously had or currently has.
Depending on the nature of an individual's condition and the accuracy of the information they access, self-diagnoses can vary greatly in their safety. Due to self-diagnoses' varied accuracy, public attitudes toward self-diagnosis include denials of its legitimacy and applause of its ability to promote healthcare access and allow for individuals to find solidarity and support. Furthermore, external influences such as marketing, social media trends, societal stigma around disease, and to which demographic population one belongs greatly affect the use of self-diagnosis.
Appropriate use
Self-diagnosis is prone to error and may be potentially dangerous if inappropriate decisions are made, which can stem from broad or inaccurately applied symptoms as well as confirmation bias. Because of the risks, self-diagnosis is officially discouraged by physicians and patient care organizations. Physicians are also discouraged from engaging in self-diagnosis due to potential lack of objectivity. An inaccurate self-diagnosis—a misdiagnosis—can result in improper health care, including using the wrong treatment or not seeking care for a serious condition that was under-diagnosed. Further concerns include undermining physician authority, lacking an unbiased view of oneself, overestimating one's symptoms, or adopting a state of denial about these symptoms.
However, self-diagnosis may be appropriate under certain circumstances. The use of over-the-counter (non-prescription) medications is often involved in self-diagnosis for conditions that are unlikely to be serious and have a low risk of harm by incorrect medication. Some conditions are more likely to be self-diagnosed, especially simple conditions such as head lice and skin abrasions or familiar conditions such as menstrual cramps, headache or the common cold. During the COVID-19 pandemic, self-diagnosis through the use of self-testing kits became commonplace and endorsed by governments, the Centers for Disease Control and Prevention (CDC) providing guidelines by which the American public should go about self-testing.
Complex conditions, including conditions like ADHD in adults and autism spectrum disorder (ASD), are more difficult to self-diagnose accurately. Such self-diagnoses are complicated by multiple factors, such as direct-to-consumer marketing of medications, which is widely criticized for promoting inappropriate self-diagnosis. Additionally, especially among younger generations, access to social media and the Internet has increased the ease with which individuals can access symptom lists and self-diagnose themselves with these complex conditions, potentially inaccurately.
Influencing factors
Marketing
Direct-to-consumer advertising
Pharmaceutical and medical companies consider self-diagnosis in their marketing strategies as a means of connecting with their consumer base. Pharmaceutical companies have put a considerable amount of funding into marketing campaigns, which a 2007 study linked to an increase in seemingly healthy patients seeking out more diagnostic screenings. Specific marketing campaigns, termed disease awareness campaigns, disseminate information about a certain condition to consumers, rather than specific patients already diagnosed, and promote specific drugs developed by a pharmaceutical company as a remedy for said condition.
Often, these campaigns are proliferated through the creation of unbranded websites with checklists of ambiguous and broad symptoms that are stated to be representative of a specific disease, which has caused the American Medical Association (AMA) to warn doctors of this form of direct-to-consumer advertising. The AMA's concern was that the symptom checklists state that a widely applicable set of symptoms are indicative of a specific condition, improperly educating consumers about the disease and convincing them to adopt that diagnosis for a condition they may not have. Ebling assesses that naming the disease gives it an increased authenticity that merits a medical solution, which the websites present to be a specific, branded drug, all without appearing to be obviously sponsored. Medical professionals have taken concern with this promotion of a medical solution, accusing it to be a means of profiting off of consumers who are attempting to treat a condition they may not have. Doctors further criticize these campaigns for being misleading because they also often use language that celebrates the agency a patient is assuming over themselves by gaining this knowledge and seeking out a solution.
These ambiguous symptom checklists have been mirrored by advertisements by medical brands on TikTok that present their content as traditional influencer posts, then asking users if they exhibit any symptoms that could be applied to various conditions, such as “Are you nervous?” From this point, like the websites, these advertisements encourage users to empower themselves to address a specific condition they might have by using the company's services, which may include consultations or specific medications.
However, there is no consensus among studies as to whether exposure to direct-to-consumer advertising leads to a higher rate of requesting brand-name drugs.
Premenstrual dysphoric disorder (PMDD)
The pharmaceutical industry has also played a role in promoting drugs that treat premenstrual dysphoric disorder (PMDD). Sarafem, a differently-branded version of Prozac, which is used to treat depression, was created during the time when Prozac's patent was soon to expire. United States patent law required Eli Lilly and Company, Prozac's developer, to present a new use for the drug to extend their patent. Ebling states that Eli Lilly sought out doctors who would support the designation of PMDD as its own disease, resulting in FDA recognition of the condition and approval of Sarafem to serve as a treatment for it. The company succeeded in avoiding the competition that would have been generated by the production of a generic version of Prozac.
Since then, PMDD has become more commonly recognized, now having its own category in the DSM-V. However, it is still not consistently recognized among healthcare professionals due to some doctors still considering it a contested condition.
Self-diagnosis kits
Self-diagnosis itself is becoming a more lucrative industry given the popularity of self-testing kits. While these are most commonly associated with COVID-19, self-testing kits exist for a wide range of conditions, such as prostate cancer, Alzheimers, and menopause. Though healthcare professionals warn of their potential to be unreliable, these kits appeal to the public due to their easy use, convenience, and inexpensiveness. Despite the fact that doctors warn that they cannot necessarily conclusively diagnose a condition nor encapsulate a disease's full complexity, the industry creating these tests is growing in profitability.
Smartphone applications
Developers of medical diagnosis applications can also be fueled by commercial interests. A number of applications receive monetary returns for acting as referrals to health insurance companies, doctor's offices, and pharmacies. These forms of monetary compensation are often not mentioned in the app's contents or general overview.
The role of stigma
Public stigma
Though self-diagnosis may work to counter the stigma associated with disease, it faces its own share of public disapproval. Those who publish posts encouraging self-diagnosis do not always have verified medical credentials even though they often present their posts as providing expert advice. As a result, self-diagnoses are not always accepted by the public because they can be seen as misleading (see later section on Use of Social Media and Webpages).
Medical experts are concerned that self-diagnosis can overemphasize and enforce stereotypical perceptions of a disorder, positing that social media posting can ignore the medical complexity of physical and mental health disorders.
Support
Self-diagnosis can provide a reprieve from societal stigma surrounding mental illness. An individual who diagnoses themselves with a condition is able to seek out online communities of others with the same condition, providing them with a sense of recognition and belonging. On TikTok, those who deem themselves to exhibit traits of conditions such as obsessive-compulsive disorder, dissociative identity disorder, and autism spectrum disorder (ASD) have found communities of support. Similarly, specific online communities exist for those with ASD, which adults with ASD report as assisting with combatting feelings of not fitting in prior to being able to identify with the disorder. Communities for health problems not necessarily recognized by the medical establishment also exist online with the same purpose of providing support and understanding.
Relatedly, self-diagnosis can foster a sense of self-understanding that promotes self-acceptance in the face of harsh social norms. This has been particularly influential for those with ASD. Those with ASD may display different behaviors than neurotypical individuals, prompting people with ASD to feel “othered.” Without an explanation as to why they may feel different than others, they have a higher likelihood of feeling confused and having low self-esteem, studies linking delayed diagnosis in individuals with ASD with higher rates of anxiety, depression, and suicidal tendencies. However, advocates for self-diagnosis posit that with an explanation, those with ASD can understand why they may feel different, alleviating this burden. This understanding can also promote a greater comprehension of their strengths, weaknesses, and symptoms, allowing them to better navigate everyday life.
Additionally, social media users argue that the prevalence of self-diagnosis has promoted an open discussion surrounding mental health, working to remove the stigmas from various diseases and conditions. Online discussion of self-diagnosis has also been espoused as a tool to provide the benefits of a diagnosis to those who face financial or geographic boundaries to receiving a professional diagnosis.
Prevalence of the internet
The Internet and other connected resources have become popular places to start the self-diagnosis process. The availability of medical information online allows patients to have greater access to medical knowledge.
Smartphone applications
There are a multitude of medical and health apps available on both the Apple App Store and Google Play Store that can be used for self-diagnosing purposes. Approximately 20% of smartphone users have a health-related application downloaded onto their device.
Experts have criticized the creators of such medical apps as promoting a false sense of credibility in order to increase the number of downloads. For example, these apps will often use widely recognized medical symbols such as the red cross or a stethoscope on their thumbnails and diagnostic pages, as well as emphasize terms such as "algorithm", "sensors", and "computer" in the diagnosis process to convey a sense of scientific objectivity. Lupton and Jutel, in their analysis of 35 self-diagnosis apps, argue that these techniques portray self-diagnosis apps as having an augmented authority in determining diagnoses.
In relation to the amount of power that health-related smartphone apps have in determining a diagnosis, researchers have emphasized the importance of using such apps judiciously. In order to maintain a balance between patient agency and professional medical authority, many self-diagnosis applications remind users of the incomplete medical certainty of the diagnosis provided and to encourage them to obtain secondary professional medical advice from a doctor or specialist. Additionally, the sources of application diagnosis information can often be difficult to determine or verify. There have been cases where certain health-related applications made claims to receiving significant contributions of content from prestigious educational institutions to increase downloads, but little information was provided as to the extent and verifiability of such contributions.
Use of chatbots
A recent technology that has started to take hold in the realm of self-diagnosis is the utilization of chatbot-based symptom checker (CSC) applications. CSCs were designed to combat the problem of extended wait times to see a doctor and the unavailability of punctual medical advice. Patients have also utilized chatbots to determine severity of their potential diagnosis before going through the process of seeing a doctor and incurring the financial strain that can come with it. Chatbots utilize artificial intelligence (AI) in order to assist patients in their medical concerns during all hours of the day. The operational mechanism of CSCs is a text-to-text system, where the chatbot asks a series of health-related questions in order to determine a diagnosis. The effectiveness of chatbots in the process of self-diagnosis is still highly debated among researchers.
Studies have found that users have varying opinions on the required input for chatbot websites and applications. In some cases, chatbots offer limited space to input multiple symptoms and locations of symptoms for diagnosis determination. Interfaces have presented users with a "pre-structured symptom selection list" which has forced users to be more general with their responses than they would prefer. Other users have felt that questions asked by self-diagnosing chatbots require too much detail, leaving them confused or overwhelmed.
People are also using AI chatbots for self-diagnosis.
Social media
Social media has started to take on a particularly important role in the process of self-diagnosis, especially the diagnosis of mental health disorders. Social media users seeking answers often self-diagnose after resonating with a particular trait of a disorder that has been mentioned in a social media post. Self-diagnosis through social media is generally more prevalent in individuals who have obsessive–compulsive disorder (OCD), anxiety, depression, or other complex trauma.
Increased access to the ability to self-diagnose via the Internet can have benefits for patient-doctor communication. By assessing a patient's self-diagnosis, a medical professional can see with which specific traits of a disease the patient identified and can work with them to create a potentially more effective diagnosis and treatment.
Self-diagnosis through social media may have some drawbacks associated with it. Some social media postings can simplify a diagnosis, leading to a spread of misinformation about the emphasized disease. Some online self-diagnosis tests state that common, broad symptoms, like anxiety and mood swings, are definite indicators of specific disorders, causing social media users to report such posts for inaccuracy. People who publish health-related posts on the self-diagnosis of health issues may not have verified medical credentials even though they have posed their post as providing expert advice. Journalist and author Doreen Dodgen-Magee considers self-diagnosis tests to work due to confirmation bias, which was witnessed when there was a statistical increase in the number of teenage girls approaching their doctors with a concern they had Tourette syndrome after multiple videos naming broad symptoms as signs of Tourettes went viral on TikTok.
Impact on varying demographics
Ethnic and socio-economic backgrounds
Vulnerable demographics
Ani and Bazargan from the Department of Family Medicine and Research Centers in Minority Institutions found that accessibility, affordability, continuity of medical care, and financial strains are the primary factors that determine whether patients choose to use self-diagnose or formal diagnoses. By utilizing the Behavioral Model for Vulnerable Populations, the study sampled over 1,394 African American and Latino households. Apart from their minority ethnic status, the households also had the following intersectional identities: 89% were female, 50% were single-parent households, 60% had less than a high school education, 73% were unemployed, and 33% were non-English speakers. Throughout the research process, 43% of the participants reported that a physician had never diagnosed at least one of their illnesses. The study's results note the significant influence of socio-economic backgrounds on using self-diagnosis as a more efficient and accessible medical solution. The study, however, also raised a concern regarding self-diagnosis in minority communities. Results show that the possibility of seeking self-diagnosis was far more likely when there were noticeable symptoms than when the symptoms were non-noticeable. If regular health checks were not offered to these demographics, they most likely would not realize their health conditions until they become irreversible. Commenting on this unrepairable outcome, Pete Wharmby, author of two books about autism, expressed frustration for non-white persons with Autism: "Autism is often undiagnosed, especially in demographics that are not young white males. This means self-diagnosis is often a requirement to get an official diagnosis. Some cannot get this dx, but still, deserve to be heard."
COVID-19 pandemic
COVID-19 also contributed to the increase in self-diagnosis among minority populations. Samantha Artiga from the Kaiser Family Foundation reports that when statistics were corrected to account for differences in age by race and ethnicity, it became clear that Black, Hispanic, AIAN, and NHOPI persons had the highest rates of COVID-19 cases and deaths in compared to white people. These demographics had a correlated surge in self-diagnosed COVID-19 cases. The Conversation highlights how using internet resources to evaluate COVID-19 symptoms and self-triage was promoted during the pandemic, exhibiting how online health information gained new significance.
The benefits and costs for vulnerable demographics
This trend of turning to self-diagnosis among minorities can be potentially dangerous, given the unfiltered and unauthorized information online. A report from Psychreg criticizes self-diagnosis for its potentially hazardous nature, reporting that 61% of the advice on social media (specifically, TikTok) is incorrect. The Camber Mental Health Organization also notes the potential danger of online self-diagnosis, indicating that influencers without proper license offer public advice that can further jeopardize the vulnerable demographics.
Other studies present non-dangerous aspects of self-diagnosis for these populations. A new study published by the Department of Public Health and Primary Care at Leiden University Medical Centre explains that patients use the internet to find reliable medical information about minor ailments and thus prevent symptoms from worsening if immediate health care cannot be provided. After surveying 1,372 participants, the study finds that most patients utilize this symptom-based approach. Suppose the patients expect the potential diagnosis to be more lethal. In that case, they tend to conduct further research on the internet to verify their suspicions about their condition.
Age
Younger generations are more likely to perform self-diagnosis. Kwakernaak explains their findings of a positive correlation between self-diagnosing accuracy and the age variable. There was an inverse relationship between age and accuracy; the younger the patient was, the more likely they would find high-quality websites for information. Kunst from Statista conducts a survey that presents the frequency data of each age group using apps for self-diagnosis. The group aged 18–19 years old were almost two times more likely to use the Internet regularly or occasionally compared to all the other age groups. The data showed that 10% of those in that age group used self-diagnosis regularly compared to 4% of respondents older than 61. The study posits that this frequent usage may explain why the younger population had more experience searching for high-quality websites and receiving accurate diagnoses. However, Kunst notes that this conclusion may be biased as the survey was conducted online and thereby only targeted respondents who had frequent access to the Internet.
See also
Cure
Cyberchondria
Home remedy
Related mental disorders:
Delusional parasitosis
Hypochondria
Medical students' disease
Morgellons
Therapy
References
Diagnosis codes
Medical terminology
ia:Autodiagnose
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Glasgow Outcome Scale
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The Glasgow Outcome Scale (GOS) is an ordinal scale used to assess functional outcomes of patients following brain injury. It considers several factors, including a patient's level of consciousness, ability to carry out activities of daily living (ADLs), and ability to return to work or school. The scale provides a structured way to classify patient outcomes into five broad categories: death, vegetative state, severe disability, moderate disability, or good recovery.
The scale was first developed by Jennett and Bond in 1975. Later, in 1981, Jennett et al. introduced the Extended Glasgow Outcome Scale (GOSE), which subdivided the upper three categories of the original scale. This resulted in the GOSE having eight outcome categories, which aimed at providing more nuanced distinction between each category.
Since their introductions, both the original and extended versions of the scale have been widely adopted in clinical practice, as well as in research studies on brain injury.
History
The Glasgow Outcome Scale was first described by Bryan Jennett and Michael Bond in 1975 as a tool to characterize both survival and quality of life after brain injury. Soon after its publication, it was used in several different large clinical studies of brain injury throughout the 1970s and early 1980s. In 1981, Jennett and his colleagues expanded the 5-point original GOS by subdividing some of the original categories, resulting in the 8-point Extended Glasgow Outcome Scale (GOSE).
Throughout the 1980s and 1990s, studies assessing the reliability of both the original and extended version of the GOS found that there was significant inter-rater variation in how patients were ranked on the scales based on the differences in background of the assessor. To address this and achieve greater consistency among different assessors, a structured interview format with clearer guidelines was developed in 1998 for both the GOS and GOSE.
The GOSE-Pediatric Revision (GOSE-Peds), introduced in 2012, is the latest development of the GOS. It uses the same 8 outcome categories as the GOSE, but modifies aspects of the structured interview to consider age and developmental differences.
Aims
The Glasgow Outcome Scale aims to characterize the overall functional outcome and quality of life in patients after sustaining brain injury. Thus, the scale reflects disability and limitations in major areas of life instead of focusing on specific impairments.
The assessment is conducted in interview format, assessing level of consciousness, independence in activities of daily living (ADLs), independence outside the home, ability to work, ability to participate in social or leisure activities, and extent of adverse impact on relationships with others. The Extended Glasgow Outcome Scale further includes assessment of other problems caused by or related to the initial injury, such as headaches, migraines, fatigue, or memory difficulty.
The Glasgow Outcome Scale and Extended Glasgow Outcome Scale are intended for use after discharge from hospital. A derivative of the GOSE, the Glasgow Outcome at Discharge Scale (GODS), was developed in 2013 for use in the inpatient setting.
Scoring
The GOS and GOSE is carried out as standardized interview assessment. In some cases, the assessor may need to obtain collateral information from a family member or close friend of the patient if the patient is unable to participate or respond reliably. Multiple sources of information can be combined to determine the final overall scoring. After the interview assessment is complete, the assessor categorizes the responses into one of the possible outcome categories outlined by the scale.
Glasgow Outcome Scale
The original Glasgow outcome scale outlined five possible outcome categories: death, persistent vegetative state, severe disability, moderate disability and good recovery.
Extended Glasgow Outcome Scale
The Extended Glasgow Outcome Scale (GOSE) subdivided the three upper categories of the original GOS. This resulted in eight total outcome categories: death, persistent vegetative state, lower severe disability, upper severe disability, lower moderate disability, upper moderate disability, lower good recovery, and upper good recovery.
Pediatric Scoring: the Glasgow Outcome Scale-Pediatric Revision
The Glasgow Outcome Scale-Pediatric Revision (GOSE-P) adjusts the interview questions to account for age and developmental differences in pediatric patients. It uses the same eight outcome categories as the GOSE.
Applications and uses
The Glasgow Outcome Scale is widely used in clinical settings to evaluate patients who have suffered brain injury. It is the recommended outcomes measure for major trauma and head injury by many national-level organizations, including the NIH National Institute of Child Health and Human Development, and the National Institute of Neurological Disorders and Stroke.
The Glasgow Outcome Scale has also been extensively used in research and clinical trials. In a 2016 review on the management of traumatic brain injury that examined over 160 randomized controlled trials published between 1980 and 2015, the GOS or GOSE was the outcome measurement reported in over two-thirds of the trials.
Challenges and limitations
Adoption
While the GOS is a widely used outcomes measure for assessing patients with brain injury, many other neurological outcome scales exist, including the Modified Rankin Scale, the Cerebral Performance Category Scale, and Functional Status Examination.
Sensitivity and reliability
Both the original GOS and the GOSE were found to have significant inter-rater variability shortly after they were introduced. This resulted in the development of a structured interview format with detailed guidelines to improve reliability and consistency between different raters. Shortly after the development of the structured interview guidelines, it was reported that use of this format greatly improved the reliability of both the GOS and GOSE. However, some critics still voice concerns over these figures, and report that inter-rater variability remains high when used by untrained assessors.
Limited scope
One criticism of the GOS is that it does not account for the patient's perspective of the injury and satisfaction with life after the injury. The GOS may not measure specific aspects of recovery or quality of life that are important to patients and families. It does not directly assess for patient satisfaction or the emotional aspects associated with the injury or recovery.
See also
Modified Rankin
Barthel scale
Disability Rating Scale
References
Diagnostic emergency medicine
Medical scales
Neuropsychological tests
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Cardiac rehabilitation
|
Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "the sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life". CR is a comprehensive model of care delivering established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life and reducing the risk of future heart problems.
CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist. Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are patient-centered.
Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology and the European Society of Cardiology, among other associations. Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator).
Cardiac rehabilitation setting
CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies. Hybrid programs are also increasingly being offered.
Cardiac rehabilitation phases
Inpatient program (phase I)
Engaging in CR before leaving the hospital can hasten patient’s recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.
Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient’s current status, and gradually progresses their therapeutic exercises.
Outpatient program (phase II)
In order to participate in an outpatient program, the patient generally must first obtain a physician's referral. It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4–6 weeks after cardiac surgery. This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues. Shorter time to start is associated with better outcomes.
Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use. A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program.
Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity.
The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered, and it is well-established that the more the better.
After CR is finished, there are long-term maintenance programs (phase III) available to interested patients, as benefits are optimized with long-term adherence. Unfortunately however, patients generally have to pay out-of-pocket for these services.
Under-use of cardiac rehabilitation
CR is significantly under-used globally. Rates vary widely.
Under-use is caused by multi-level factors; a recent review is available. At the health system level, this includes lack of available programs. At the provider level, low referral rates are a major barrier. At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible, but most can be mitigated. Women, ethnocultural minorities, older patients, those of lower socio-economic status, with comorbidities, and living in rural areas are less likely to access CR, despite the fact that these patients often need it most. Cardiac patients can assess their CR barriers here, and receive suggestions on how to overcome them: https://globalcardiacrehab.com/For-Patients.
Strategies are now established on how we can mitigate these barriers to CR use. It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html). It is also key for healthcare providers to promote CR to patients at the bedside. The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend CR.
Training more healthcare professionals to deliver CR can also help. CR programs can also join a registry to assess and improve their utilization—among other quality indicators. Offering programs tailored to under-served groups such as women may also facilitate program participation.
Benefits
Participation in CR may be associated with many benefits. For acute coronary syndrome patients, CR reduces cardiovascular mortality by 25% and readmission rates by 20%. The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence.
CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity, and is cost-effective. In low and middle-income countries, there is some evidence that CR is effective in improving functional capacity, risk factors and quality of life as well.
There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same. Home-based CR is generally safe. Home-based programs with technology are similarly shown to be effective.
There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues, atrial fibrillation, heart transplant recipients, and heart failure.
Cardiac rehabilitation societies
CR professionals work together in many countries to optimize service delivery and increase awareness of CR. The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations, ICCPR seeks to promote CR in low-resource settings, among other aims outlined in their Charter.
References
Rehabilitation medicine
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Social pedagogy
|
Social pedagogy describes a holistic and relationship-centred way of working in care and educational settings with people across the course of their lives. In many countries across Europe (and increasingly beyond), it has a long-standing tradition as a field of practice and academic discipline concerned with addressing social inequality and facilitating social change by nurturing learning, well-being and connection both at an individual and community level. The term 'pedagogy' originates from the Greek pais (child) and agein (to bring up, or lead), with the prefix 'social' emphasising that upbringing is not only the responsibility of parents but a shared responsibility of society. Social pedagogy has therefore evolved in somewhat different ways in different countries and reflects cultural and societal norms, attitudes and notions of education and upbringing, of the relationship between the individual and society, and of social welfare provision for its marginalised members. Social pedagogues (professionals who have completed a qualification in social pedagogy) work within a range of different settings, from early years through adulthood to working with disadvantaged adult groups as well as older people. To achieve a holistic perspective within each of these settings, social pedagogy draws together theories and concepts from related disciplines such as sociology, psychology, education, philosophy, medical sciences, and social work.
Methods
Hämäläinen points out that social pedagogy is not a method or a set of methods, but that any method is chosen based on social pedagogical considerations. In the past 3 main methods were defined:
Individual case work – with the aim to improve/develop individual life circumstances,
Social group work – with the aim of developing social competences,
Community intervention work – with the aim to develop social demographic structures.
After 1970 a lot of different methods derived from those three. In practice a mono-methodical approach can be barely found; approaches/ concepts of action predominate which include more than the three classic methods.
Principles
Social pedagogy is based on humanistic values stressing human dignity, mutual respect, trust, unconditional appreciation, and equality, to mention but a few. It is underpinned by a fundamental concept of children, young people and adults as equal human beings with rich and extraordinary potential and considers them competent, resourceful and active agents.
In their earlier work on social pedagogy, Petrie et al. identify 9 principles underpinning social pedagogy:
"A focus on the child as a whole person, and support for the child’s overall development;
The practitioner seeing herself/himself as a person, in relationship with the child or young person;
Children and staff are seen as inhabiting the same life space, not as existing in separate hierarchical domains;
As professionals, pedagogues are encouraged constantly to reflect on their practice and to apply both theoretical understandings and self-knowledge to the sometimes challenging demands with which they are confronted;
Pedagogues are also practical, so their training prepares them to share in many aspects of children’s daily lives and activities;
Children’s associative life is seen as an important resource: workers should foster and make use of the group;
Pedagogy builds on an understanding of children’s rights that is not limited to procedural matters or legislated requirements;
There is an emphasis on team work and on valuing the contribution of others in 'bringing up' children: other professionals, members of the local community and, especially, parents.
The centrality of relationship and, allied to this, the importance of listening and communicating."
Eichsteller & Holthoff suggest that social pedagogy aims to achieve:
Holistic education – education of head (cognitive knowledge), heart (emotional and spiritual learning), and hands (practical and physical skills);
Holistic well-being – strengthening health-sustaining factors and providing support for people to enjoy a long-lasting feeling of happiness;
To enable children, young people as well as adults to empower themselves and be self-responsible persons who take responsibility for their society;
To promote human welfare and prevent or ease social problems.
They go on to describe social pedagogical practice as a holistic process creating a balance between:
the professional: (theory and concepts, reflective practitioner – the ‘head’)
the personal: (using one's personality, positive attitude, building personal relationships, but keeping the ‘private’ out – the ‘heart’)
the practical: (using certain methods and creative activities – the ‘hands’)
All three elements are equal and complement each other, thus generating synergy.
Historic development
Although pedagogy varies across European countries, there are similar roots that have developed into differing strands of contemporary thinking in pedagogy. Hämäläinen explains that “historically, social pedagogy is based on the belief that you can decisively influence social circumstances through education” – and importantly, education is seen as a lifelong learning process that does not only refer to children but includes educating adults, for instance in order to change their idea of children.
While philosophers of Classical antiquity like Plato and Aristotle discussed how education could contribute to social development, social pedagogy in theory and practice only emerged through the influence of modern thinking in the Renaissance, the Reformation and later during the Enlightenment, when children started to come into the picture of social philosophy.
Jean-Jacques Rousseau
A major impetus for the current understanding of pedagogy was the educational philosophy of the Swiss social thinker Jean-Jacques Rousseau (1712–1778). Concerned with the decay of society, he developed his theories based on his belief that human beings were inherently good as they were closest to nature when born, but society and its institutions corrupted them and denaturalized them. Consequently, bringing up children in harmony with nature and its laws so as to preserve the good was central for Rousseau's pedagogic theory. Rousseau innovatively “argued that the momentum for learning was provided by the growth of the person (nature) – and that what the educator needed to do was to facilitate opportunities for learning,” as Doyle and Smith note.
Johann Heinrich Pestalozzi
Rousseau's educational philosophy inspired ensuing pedagogues, notably Johann Heinrich Pestalozzi (1746–1827), who refined Rousseau's thoughts by developing a method of holistic education, which addressed head, heart, and hands. These three elements are inseparable from each other in Pestalozzi's method and need to be kept in harmony. "Nature forms the child as an indivisible whole, as a vital organic unity with many sided moral, mental, and physical capacities. Each of these capacities is developed through and by means of the others," Pestalozzi stated.
New Education Movement
Pestalozzi's ideas sparked interest across continental Europe, and particularly the New Education Movement transferred his pedagogic concept into various settings, such as kindergarten (Fröbel), school (Montessori, Steiner, Hahn), residential care (Korczak), and informal work with children and young people (Montessori). Thus the New Education Movement contributed to a continental pedagogic discourse, which saw children being conceptualised as equal human beings ("Children do not become humans, they already are", Korczak), and as competent, active agents ("A child has a hundred languages", Malaguzzi). Furthermore, there was increasing recognition for child participation and children's rights, for instance in the pedagogic concepts of Montessori and Korczak.
The New Education Movement led to a spread of pedagogic concepts and ideas across many European countries and made two fundamental points which demonstrate its ambition to use pedagogy for social change: “First, in all education the personality of the child is an essential concern; second, education must make for human betterment, that is for a New Era”.
Alleviating poverty
Based on the educational ideas of Rousseau, Pestalozzi and Fröbel, the German headteacher Friedrich Diesterweg (1790—1866) emphasised the social relevance of pedagogy in fighting social inequalities. For him social pedagogy was "educational action by which one aims to help the poor in society". Through the contribution of Diesterweg and other thinkers, such as Friedrich Schleiermacher, pedagogy took on a more social role, one of community education that also occurs in later writers like Paulo Freire and John Dewey.
Although pedagogy was early on concerned with changing social conditions through education – Rousseau is most famous for his Social Contract (1762) – its primary focus had been on the individual and his or her upbringing, which Rousseau had aimed to protect from the negative influences of society. Pedagogic thinkers like Pestalozzi and later on Montessori followed in his tradition of developing a child-centred pedagogy, which was increasingly criticised by an emerging school of thought that promoted a pedagogy focused on the collective, on the community and how to use pedagogic ideas for social betterment – or a social pedagogy, as the German educationalist Karl Mager had written in 1844 for the first time.
Social pedagogy
One of the first key thinkers, Paul Natorp, “claimed that all pedagogy should be social, that is, that in the philosophy of education the interaction of educational processes and society must be taken into consideration”. His social pedagogic theories were influenced by Plato’s doctrine of ideas, together with Immanuel Kant’s categorical imperative of treating people as subjects in their own rights instead of treating them as means to an end, and Pestalozzi’s method.
In the 1920s, with influential educationalists such as Herman Nohl, German social pedagogy was interpreted from a hermeneutical perspective, which acknowledged that an individual’s life and their problems can only be understood through their eyes and in their social context, by understanding how the individual interacts with their social environment.
Following World War II and the experiences within National Socialism that exposed the dangers of collective education in the hands of a totalitarian state, social pedagogy “became more critical, revealing a critical attitude towards society and taking the structural factors of society that produce social suffering into consideration”. Consequently, contemporary social pedagogy in Germany is as a discipline linked more closely to social work and sociology than to psychology.
Due to different historical developments and cultural notions, social pedagogy has very different traditions in other countries, although these are connected through the overarching core principles of social pedagogy. And even within one country, there is not the pedagogic approach – within the general discipline pedagogy we can distinguish various approaches. Some of these are named after key thinkers like Fröbel or Montessori who have created a very specific pedagogic concept for the context of their work, while others are termed according to the medium they are utilising, such as adventure, play, circus, music, or theatre pedagogy.
Qualifying as a social pedagogue
Similar to other academic disciplines, social pedagogy is a degree-level qualification (higher education) of usually 3.5 years. There are different education routes to qualify as a social pedagogue, which vary from country to country:
Germany
In Germany social pedagogy and social work have merged into one course – ‘Soziale Arbeit’- since 2007 graduates holding after successful study a double degree: Social Worker and Social Pedagogy.
Social Pedagogy can be studied at Fachhochschule (Universities of applied Sciences) and universities, social pedagogy is offered as Bachelor of Arts (3.5 years) with 1 semester of practical placement as part of the curriculum- Graduates will have the ability to place their professional activity in legal and socio-political perspective and analyse it. The interplay of work experience in their placement and theoretical work in the university prepares the graduates to work with clients, in the field of administration and management of social organisations. For a deeper more research based study Social Pedagogy can be studied after the Bachelor as Master of Arts (2 years).
Social Pedagogy is multidisciplinary – the study includes:
Psychology
Sociology
Pedagogy / Education Theory
Social Work
Social Management
Law and Politics
Professional Concepts such as Mediation, Therapy, Supervision, communication concepts.
Media
Economy
Social Justice
Health
Theatre pedagogy
Denmark
Danish social pedagogues usually qualify at Seminariets (seminariums), which offer 3.5 year courses that include 3 placements in different pedagogic settings throughout the period of studies. Some seminariums also offer short courses on social pedagogy in English. Further studies at MA level often combine social pedagogy with interlinked disciplines, such as social work, sociology or psychology, and can be pursued at several universities.
Czech Republic and Slovakia
Czech and also Slovak social pedagogues usually study at the university level (there is also possibility to study at the college where they will get a DiS. degree). Social Pedagogy is offered as a Bachelor study programme. For research based studies, Social Pedagogy can be studied as Master programme after finishing the bachelor's degree. The academics separate Social Pedagogy from the social work and they look at them as at two separate disciplines.
In Slovakia is Social pedagogy a part of professional network in Educational and psychological centres (as part of school facilities) and also in schools.
North America
In the United States, Arizona State University's School of Social Transformation offers a master of arts degree in social and cultural pedagogy. The 30-unit program requires 10 three-credit courses. The core courses (9 credits) include Foundations of Social Transformation, Research Methods, and Social and Cultural Pedagogy: Theoretical and Practical Issues. Students complete five elective courses (15 credits) and then either a thesis or a capstone project (6 credits). The program develops students' capacity to analyze non-formal education policies and practices and examine the educational impact of a range of institutions, organizations and associational spaces. It provides training and skills for work in settings such as: adult education, community organizing, literacy programs, museum education, dis/ability programs, youth and sports programs, peace education, environmental education, religious organizations, health education, civic education, Indigenous and tribal communities, for-the-job and on-the-job training. There is also a professional organization, the Social Pedagogy Association (SPA), which was established as a 501(c)3 nonprofit in 2016 by graduates of the social and cultural pedagogy masters program at ASU. The goal of SPA is to encourage and track the growth of social pedagogy in the United States.
United Kingdom
A variety of qualifications are now available in the UK, ranging from a Level 3 qualification to BA programmes to a master's degree. Since February 2017 the Social Pedagogy Professional Association has acted as a professional home for social pedagogy in the UK. As a membership organisation it has developed social pedagogy standards of proficiency and standards for education and training.
Slovenia
In Slovenia social pedagogues usually study at the university level. Social Pedagogy is offered as a Bachelor study programme and as Master programme after finishing the bachelor's degree. The academics separate Social Pedagogy from the social work and they look at them as at two separate disciplines.
See also
Theatre pedagogy
Free school movement
References
Further reading
Cameron, C. & Moss, P. (2011). Social Pedagogy and Working with Children. London: Jessica Kingsley.
Charfe, L. & Gardner, A. (2019). Social Pedagogy and Social Work. London: Sage
Hatton, K. (2013). Social Pedagogy in the UK: Theory and Practice. Lyme Regis: Russell House.
Kornbeck, J. & Rosendal Jensen, N. (2009). The Diversity of Social Pedagogy in Europe. Bremen: Europäischer Hochschulverlag.
Kornbeck, J. & Rosendal Jensen, N. (2011). Social Pedagogy for the Entire Lifespan: Volume I. Bremen: Europäischer Hochschulverlag.
Kornbeck, J. & Rosendal Jensen, N. (2012). Social Pedagogy for the Entire Lifespan: Volume II. Bremen: Europäischer Hochschulverlag.
Petrie, P. & Moss, P. (2002). From Children's Services to Children's Spaces. London: Routledge.
Petrie, P. (2011). Communication Skills for Working with Children and Young People: Introducing Social Pedagogy. London: Jessica Kingsley.
Stephens, P. (2013). Social Pedagogy: Heart and Head. Bremen: Europäischer Hochschulverlag.
Storø, J. (2013). Practical Social Pedagogy: Theories, Values and Tools for Working with Children and Young People. Bristol: Policy Press.
Further information
http://www.internationaljournalofsocialpedagogy.com – the articles in the International Journal of Social Pedagogy reflect the cross-cultural perspectives of a wide range of social pedagogical traditions and provide a greater understanding of social pedagogy in ways that are both relevant at a practice level and contribute to the body of theory and research
http://www.sppa-uk.org - The Social Pedagogy Professional Association is the professional home for social pedagogy in the UK
http://www.social-pedagogy.org.uk/spdn/ - The Social Pedagogy Development Network offers a free forum for anyone interested in social pedagogy
http://www.socialpedagogyuk.com – The official website for social pedagogy in the UK, run by TCRU, NCERCC, Jacaranda Recruitment and ThemPra Social Pedagogy
http://www.thempra.org.uk – ThemPra Social Pedagogy website for further information on social pedagogy and ThemPra's courses, qualifications and systemic change strategies
http://www.jacaranda-development.co.uk – Jacaranda Development website for further information on social pedagogy and Jacaranda's training courses, field trips and consultancy
http://www.infed.org – The Online Encyclopaedia for Informal Education has various articles on social pedagogy, related themes and key thinkers
http://www.communitycare.co.uk – Community Care have published both news articles and research reports on social pedagogy over the last few years
http://www.cypnow.com – Children and Young People Now report regularly on news and developments regarding social pedagogy
http://www.socmag.net – The International Social Work and Society News Magazine brings together news from practice in the social sector across the globe, with the 7th edition including an article on the developments around social pedagogy in the UK
http://www.socialpedagogy.org - The Social Pedagogy Association of the United States, dedicated to the growth and development of social pedagogy in the United States
Alternative education
Pedagogical disciplines
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CAGE questionnaire
|
The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used screening test for problem drinking and potential alcohol problems. The questionnaire takes less than one minute to administer, and is often used in primary care or other general settings as a quick screening tool rather than as an in-depth interview for those who have alcoholism. The CAGE questionnaire does not have a specific intended population, and is meant to find those who drink excessively and need treatment. The CAGE questionnaire is reliable and valid; however, it is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE questionnaire have been frequently implemented for such a purpose.
Overview
The CAGE questionnaire asks the following questions:
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
Two "yes" responses indicate that the possibility of alcoholism should be investigated further.
The CAGE questionnaire, among other methods, has been extensively validated for use in identifying alcoholism. CAGE is considered a validated screening technique with high levels of sensitivity and specificity. It has been validated via receiver operating characteristic analysis, establishing its ability to screen for problem drinking behaviors.
History
The CAGE questionnaire was developed in 1968 at North Carolina Memorial Hospital to combat the paucity of screening measures to detect problem drinking behaviors. The original study, conducted in a general hospital population where 130 patients were randomly selected to partake in an in-depth interview, successfully isolated four questions that make up the questionnaire today due to their ability to detect the sixteen alcoholics from the rest of the patients.
Reliability
Reliability refers to whether the scores are reproducible. Not all of the different types of reliability apply to the way that the CAGE is typically used. Internal consistency (whether all of the items measure the same construct) is not usually reported in studies of the CAGE; nor is inter-rater reliability (which would measure how similar peoples' responses were if the interviews were repeated again, or different raters listened to the same interview).
Validity
Validity describes the evidence that an assessment tool measures what it was supposed to measure. There are many different ways of checking validity. For screening measures such as the CAGE, diagnostic accuracy and discriminative validity are probably the most useful ways of looking at validity.
*Table from Youngstrom et al., extending Hunsley & Mash, 2008; *indicates new construct or category
Limitations
The CAGE is designed as a self-report questionnaire. It is obvious to the person what the questions are about. Because talking about drinking behavior can be uncomfortable or stigmatized, people's responses may be subject to social desirability bias. The honesty and accuracy of responses may improve if the person trusts the person doing the interview or interpreting the score. Responses also may be more honest when the form is completed online, on a computer, or in other anonymous formats.
Alternatives
Some alternatives to the CAGE include:
See also
CRAFFT Screening Test
List of diagnostic classification and rating scales used in psychiatry
Paddington Alcohol Test
Severity of Alcohol Dependence Questionnaire
Substance abuse
References
External links
Online version of the CAGE questionnaire
AACAP practice parameters for assessment and treatment of children and adolescents with substance use disorders
Drinking culture
Alcohol abuse screening and assessment tools
| 0.763912 | 0.978836 | 0.747744 |
Haplology
|
Haplology (from Greek "simple" and , "speech") is, in spoken language, the elision (elimination or deletion) of an entire syllable or a part of it through dissimilation (a differentiating shift that affects two neighboring similar sounds). The phenomenon was identified by American philologist Maurice Bloomfield in the 20th century. Linguists sometimes jokingly refer to the phenomenon as "haplogy", an autology. As a general rule, haplology occurs in English adverbs of adjectives ending in "le", for example gentlely → gently; ablely → ably.
Examples
Basque: → ('apple cider')
German: → (female 'wizard' or 'magician'; male: der Zauberer; female ending -in); this is a productive pattern applied to other words ending in (spelt) -erer.
Dutch: → ('narcissism')
French: → ('femininity')
English:
Old English → Engle lond → England (expected form would be *Engelland)
Old English cyning → English king (expected form would be *kinning)
morphophonology → morphonology
conservativism → conservatism
mononomial → monomial
urine analysis → urinalysis
Colloquial (non-standard and eye dialect spellings signalled by *):
library (RP: ) → *libry
particularly → *particuly
probably → *probly
February → *Febury, Febuary or *Febr(u)y (compare e.g. Austrian German )
representative → *representive
authoritative → *authoritive
deteriorate → *deteriate
Latin:
→ ('nurse')
→ (hence idolatry)
Biological Latin:
Hamamelididae (disallowed spelling: Hamamelidae)
Nycterididae → Nycteridae
Anomalocaridid → Anomalocarid
Homeric Greek: → ('two-handled pitcher, amphora')
Arabic:
→ ('you are fighting each other')
→ ('I eat')
Spanish: → ('lack of modesty', i.e. the nominal form of , 'immodest')
Portuguese:
→ (aged person, senior)
→ (feminism)
Colloquially in sequences like campo pequeno pronounced like "campequeno" or faculdade de letras pronounced like "faculdadletras".
Italian:
tragico-comico → tragicomico ('tragicomic')
domani mattina → domattina ('tomorrow morning')
Reduplication
The reverse process is known as reduplication, the doubling of phonological material.
See also
Haplography
Dissimilation
Portmanteau
Notes
References
Crowley, Terry. (1997) An Introduction to Historical Linguistics. 3rd edition. Oxford University Press.
Phonology
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Medical encyclopedia
|
A medical encyclopaedia is a comprehensive written compendium that holds information about diseases, medical conditions, tests, symptoms, injuries, and surgeries. It may contain an extensive gallery of medicine-related photographs and illustrations.
A medical encyclopaedia provides information to readers about health questions. It may also contain some information about the history of diseases, the development of medical technology uses to detect diseases in its early phase.
A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions.
Characteristics
Four major elements define a medical encyclopaedia: its subject matter, its scope, its method of organization, and its method of production:
Encyclopaedias can be general, containing articles on topics in every field. A medical encyclopedia provides valuable health information, tools for managing your health, and support to those who seek information.
Works of encyclopedic scope aim to convey the important accumulated knowledge for their subject domain, such as an encyclopaedia of medicine.
The articles on subjects in a medical encyclopedia are usually accessed alphabetically by article name or for health topics.
As modern multimedia and the information age have evolved, they have had an ever-increasing effect on the collection, verification, summation, and presentation of information of all kinds. Medical encyclopedias such as Medline Plus, WebMD, and the Merck Manual are examples of new forms of the medical encyclopedias as information retrieval becomes simpler. Some online encyclopedias are medical wikis, which use wiki software to write the information collaboratively.
Listing of Medical Encyclopedias
A.D.A.M. Medical Encyclopedia (MedlinePlus)
A.D.A.M (Animated Dissection of Anatomy for Medicine) contains articles discussing diseases, tests, symptoms, injuries and surgeries. Content is reviewed by physicians; the goal is to present evidence-based health information. It also contains a library of medical photographs and illustrations. MedlinePlus is a free Web site that provides consumer health information for patients, families, and health care providers. MedlinePlus brings together information from the United States National Library of Medicine, the National Institutes of Health (NIH), other U.S. government agencies, and health-related organizations. The U.S. National Library of Medicine produces and maintains MedlinePlus.
WebMD
WebMD is an American provider of health information services. It is primarily known for its public Internet site, which has information regarding health and health care, including a symptom checklist, pharmacy information, blogs of physicians with specific topics and a place to store personal medical information. The site was reported to have received over 17.1 million average monthly unique visitors in Q1 2007 and is the leading health portal in the United States. The site receives information from accredited individuals and is reviewed by a medical review board consisting of four physicians to ensure accuracy.
Medscape is a professional portal for physicians with 30 medical specialty areas and over 30 physician discussion boards. Recently WebMD has been acquired by the News Corporation.
MedicineNet
MedicineNet, Inc. is owned and Operated by WebMD and part of the WebMD Network emphasizing non-technical, medical peer-reviewed information for consumers. Founded in 1996, WebMD acquired MedicineNet in 2004. MedicineNet, Inc.'s main office is in San Clemente, Calif., and the corporate office is in New York City.
See also
Pharmacopoeia, a list of medications and their properties
Materia medica, an encyclopedia of medications
List of medical wikis
List of online encyclopedias
References
External links
Medical Encyclopedia WebMD
Medical Encyclopedia MayoClinic
Medical Encyclopedia University of Maryland Medical Center
Encyclopedia of the Human Body. 3D Human Anatomy Model
HealthCareMagic
Medical equipment
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Musicophilia
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In 2007, neurologist Oliver Sacks released his book Musicophilia: Tales of Music and the Brain in which he explores a range of psychological and physiological ailments and their intriguing connections to music. It is broken down into four parts, each with a distinctive theme; part one titled Haunted by Music examines mysterious onsets of musicality and musicophilia (and musicophobia). Part two A Range of Musicality looks at musical oddities musical synesthesia. Parts three and four are titled Memory, Movement, and Music and Emotions, Identity, and Music respectively. Each part has between six and eight chapters, each of which is in turn dedicated to a particular case study (or several related case studies) that fit the overarching theme of the section. Presenting the book in this fashion makes the reading a little disjointed if one is doing so cover to cover, however, it also means one may pick up the book and flip to any chapter for a quick read without losing any context. Four case studies from the book are featured in the NOVA program Musical Minds aired on June 30, 2009.
Purpose
According to Sacks, Musicophilia was written in an attempt to widen the general populace's understanding of music and its effects on the brain. As Sacks states at the outset of the book's preface, music is omnipresent, influencing human's everyday lives in how we think and act. However, unlike other animal species (such as birds) whose musical prowess is easier to understand in relation on a biological/evolutionary level, humanity's draw towards music and song is less clear-cut. There is no "music center" of the brain, yet the vast majority of humans have an innate ability to distinguish, "music, perceive tones, timbre, pitch intervals, melodic contours, harmony, and (perhaps most elementally) rhythm." With that in mind, Sacks examines human's musical inclination through the lens of musical therapy and treatment, as a fair number of neurological injuries and diseases have been documented to be successfully treated with music. This understanding (along with a medical case Sacks witnessed in 1966 wherein a Parkinson's patient was able to be successfully treated via music therapy) is what galvanized Sacks to create an episodic compilation of patient cases that all experienced and were treated by music to some capacity. In doing so, Sacks concertizes each example by explaining the neurological factors that play into each patient's healing and treatment in ways that relate to a lay yet curious audience.
Reviews
In a review for The Washington Post, Peter D. Kramer wrote, "In Musicophilia, Sacks turns to the intersection of music and neurology—music as affliction and music as treatment." Kramer wrote, "Lacking the dynamic that propels Sacks's other work, Musicophilia threatens to disintegrate into a catalogue of disparate phenomena." Kramer went on to say, "What makes Musicophilia cohere is Sacks himself. He is the book's moral argument. Curious, cultured, caring, in his person Sacks justifies the medical profession and, one is tempted to say, the human race." Kramer concluded his review by writing, "Sacks is, in short, the ideal exponent of the view that responsiveness to music is intrinsic to our makeup. He is also the ideal guide to the territory he covers. Musicophilia allows readers to join Sacks where he is most alive, amid melodies and with his patients."
Musicophilia was listed as one of the best books of 2007 by The Washington Post.
Music and the brain
Sacks includes discussions of several different conditions associated with music as well as conditions that are helped by music. These include musical conditions such as musical hallucinations, absolute pitch, and synesthesia, and non-musical conditions such as blindness, amnesia, and Alzheimer's disease.
Musical conditions
Sacks first discusses musical seizures, and he mainly writes about someone who had a tumor in his left temporal lobe which caused him to have seizures, during which he heard music. Sacks then writes about musical hallucinations that often accompany deafness, partial hearing loss, or conditions like tinnitus. Sacks also focuses a lot on absolute pitch, where a person is able to immediately identify the pitch of a musical note. Another condition Sacks spends a lot of time on is synesthesia. Sacks discusses several different types of synesthesia: key synesthesia, non-musical synesthesia centered on numbers, letters, and days, synesthesia centered on sounds in general, synesthesia centered on rhythm and tempo, and synesthesia in which the person sees lights and shapes instead of colors. Sacks also describes cases where synesthesia has accompanied blindness.
Conditions affected
Sacks discusses how blindness can affect the perception of music and musical notes, and he also writes that absolute pitch is much more common in blind musicians than it is in sighted musicians. Sacks writes about Clive Wearing, who suffers from severe amnesia. Sacks writes about how, even though Clive suffers from such severe amnesia, he still remembers how to read piano music and play the piano. However, Clive can only remember how to do so in the moment. Sacks also writes about Tourette syndrome and the effects that music can have on tics, for example, slowing tics down to match the tempo of a song. Sacks writes about Parkinson's disease, and how, similar to with people who suffer from Tourette's, music with a strong rhythmic beat can help with movement and coordination. Sacks briefly discusses Williams syndrome and how children with Williams syndrome were found to be very responsive to music. Sacks finishes his book with a discussion of Alzheimer's disease and dementia. He discusses how music therapy can help people with these conditions regain memory.
Behavioral effects
Certain portions of the brain are associated with how we use the brain to interact with music. For example, the cerebellum, a portion that coordinates movement and stores muscle memory, responds well to the introduction of music. For example, an Alzheimer's patient would not be able to recognize his wife, but would still remember how to play the piano because he dedicated this knowledge to muscle memory when he was young. Those memories never fade. Another example is the Putamen. This portion of the brain processes rhythm and regulates body movement and coordination. When introduced to music, if the amount of dopamine in the area is increased, it increases our response to rhythm. By doing this, music has the ability to temporarily stop the symptoms of such diseases as Parkinson's Disease. The music serves as a cane to these patients, and when the music is taken away, the symptoms return. When it comes to which music people respond best to, it is a matter of individual background. In patients with dementia, it is found that most patients respond to music from their youth, rather than relying on a certain rhythm or element. Neuroscientist Kiminobu Sugaya explains "That means memories associated with music are emotional memories, which never fade out-even in Alzheimer's patients".
Studies on the effects of music therapy
Since the 1970s, there have been multiple studies on the benefits of music therapy for clients with medical conditions, trauma, learning disabilities, and handicaps. Most of the documented studies for children have shown a positive effect in promoting self-actualization and developing receptive, cognitive, and expressive capabilities. While the studies conducted with adults 18+ had overall positive effects, the conclusions were limited because of overt bias and small sample sizes.
Since music is a fundamental aspect of every culture, it embodies every human emotion and can even transport us to an earlier time through our memory. Oliver Sacks, author of Musicophilia, acknowledges the unconscious effects of music as our body tends to join in the rhythmic motions involuntarily. Working with clients with a variety of neurological conditions, Sacks observed the therapeutic potential and susceptibility to music. Even with the loss of language, music becomes the vehicle for expression, feeling, and interaction.
Well-known music therapists Paul Nordoff and Clive Robbins documented their work with audio recordings and videos of the transformative results of music with children who had emotional or behavioral problems, traumatic experiences, or handicaps. Robbins classifies the "Music Child" as the inner self in every child that evokes a healthy musical response. It is music that becomes the catalyst for discovering the child’s potential. In essence, musical play creates an atmosphere that emboldens a child to free expression and reproductive skills. Sometimes family members observe immediate effects because selfhood is encouraged and nurtured and thus a child’s personality develops in response to music.
First, the music therapist assesses each client to determine impairments, preferences, and skill level. Notably, every person appreciates different musical genres. Next, treatment is determined based on individualized goals and selection as well as frequency and length of sessions. Finally, the progress of the client is evaluated and updated based on effectiveness. Although sessions are typically structured, therapist also remain flexible and try to meet clients where they are at emotionally and physically.
When music therapy was first introduced in tandem with other medical fields, it was mostly receptive and patients listened to live solo performances or pre-recorded songs. Today, music therapist allow for more creative interactions by having clients improvise, reproduce music or imitate melodies vocally or with an instrument, compose their own songs, and/or listen during artistic expression or with movement.
Recently, studies have been conducted on the effects of music with chemo patients, stroke patients, patients with Alzheimer, spinal or brain injury, and hospice patients. According to a 2017 report from Magee, Clark, Tamplin, and Bradt, a common theme of all their studies was the positive effect music had on mood, mental and physical state, increase in motivation and social engagement, and a connection with the client’s musical identity. From 2008-2012, the Department of Oncology/ Hematology of the University Medical Center in Hamburg-Eppendorf orchestrated a randomized pilot study to determine if music therapy helped patients cope with pain and reduce chemotherapy side effects. The sessions were given twice a week for twenty minutes and patients could choose either receptive or active methods. Each week, the quality of life, functioning ability, and level of depression/anxiety were assessed. Although emotional functioning scores increased and perception of pain improved significantly, they determined the outcome was inconclusive because patients have differing levels of manageable side effects and a hope to survive may influence expectations of treatment. However, patients rated the program helpful and potentially beneficial. Moreover, the feasibility of these studies allows for music therapists to practice in educational, psychiatric, medical, and private settings. Although there haven’t been any statistical significance based on few empirical adult studies, the trend shows improvements on most measures.
References
External links
Musicophilia at author's website
2007 non-fiction books
Books by Oliver Sacks
Neuroscience books
Music books
Picador (imprint) books
Books with cover art by Chip Kidd
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Guided imagery
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Guided imagery (also known as guided affective imagery, or katathym-imaginative psychotherapy) is a mind-body intervention by which a trained practitioner or teacher helps a participant or patient to evoke and generate mental images that simulate or recreate the sensory perception of sights, sounds, tastes, smells, movements, and images associated with touch, such as texture, temperature, and pressure, as well as imaginative or mental content that the participant or patient experiences as defying conventional sensory categories, and that may precipitate strong emotions or feelings in the absence of the stimuli to which correlating sensory receptors are receptive.
The practitioner or teacher may facilitate this process in person to an individual or a group or you may do it with a virtual group. Alternatively, the participant or patient may follow guidance provided by a sound recording, video, or audiovisual media comprising spoken instruction that may be accompanied by music or sound.
Mental imagery in everyday life
There are two fundamental ways by which mental imagery is generated: voluntary and involuntary.
The involuntary and spontaneous generation of mental images is integral to ordinary sensory perception, and cognition, and occurs without volitional intent. Meanwhile, many different aspects of everyday problem solving, scientific reasoning, and creative activity involve the volitional and deliberate generation of mental images.
Involuntary
The generation of involuntary mental imagery is created directly from present sensory stimulation and perceptual information, such as when someone sees an object, creates mental images of it, and maintains this imagery as they look away or close their eyes; or when someone hears a noise and maintains an auditory image of it, after the sound ceases or is no longer perceptible.
Voluntary
Voluntary mental imagery may resemble previous sensory perception and experience, recalled from memory; or the images may be entirely novel and the product of fantasy.
Technique
The term guided imagery denotes the technique used in the second (voluntary) instance, by which images are recalled from long-term or short-term memory, or created from fantasy, or a combination of both, in response to guidance, instruction, or supervision. Guided imagery is, therefore, the assisted simulation or re-creation of perceptual experience across sensory modalities.
Clinical investigation and scientific research
Mental imagery can result from both voluntary and involuntary processes, and it comprises simulation or recreation of perceptual experience across all sensory modalities, including olfactory imagery, gustatory imagery, haptic imagery, and motor imagery. Nonetheless, visual and auditory mental images are reported as being the most frequently experienced by people ordinarily as well as in controlled experiments, with visual imagery remaining the most extensively researched and documented in scientific literature.
In experimental and cognitive psychology, researchers have concentrated primarily on voluntary and deliberately generated imagery, which the participant or patient creates, inspects, and transforms, such as by evoking imagery of an intimidating social event, and transforming the images into those indicative of a pleasant and self-affirming experience.
In psychopathology, clinicians have typically focused on involuntary imagery which "comes to mind" unbidden, such as in a depressed person's experience of intrusive unwelcome negative images indicative of sadness, hopelessness, and morbidity; or images that recapitulate previous distressing events that characterize posttraumatic stress disorder.
In clinical practice and psychopathology, involuntary mental images are considered intrusive when they occur unwanted and unbidden, "hijacking attention" to some extent.
The maintenance of, or "holding in mind" imagery, whether voluntary or involuntary, places considerable demands upon cognitive attentional resources, including working memory, redirecting them away from a specific cognitive task or general-purpose concentration and toward the imagery.
In clinical practice, this process can be positively exploited therapeutically by training the participant or patient to focus attention on a significantly demanding task, which successfully competes for and directs attention away from the unbidden intrusive imagery, decreasing its intensity, vividness, and duration, and consequently alleviating distress or pain.
Mental imagery and ill health
Mental imagery, especially visual and auditory imagery, can exacerbate and aggravate a number of mental and physical conditions.
This is because, according to the principles of psychophysiology and psychoneuroimmunology, the way an individual perceives his or her mental and physical condition in turn affects biological processes, including susceptibility to illness, infection, or disease; and that perception is derived significantly from mental imagery. That is to say that in some cases, the severity of an individual's mental and physical disability, disorder, or illness is partially determined by his or her images, including their content, vividness or intensity, clarity, and frequency with which they are experienced as intrusive and unbidden.
An individual can aggravate the symptoms and intensify the pain or distress precipitated by many conditions through generating, often involuntarily, mental imagery that emphasizes its severity.
For example, mental imagery has been shown to play a key role in contributing to, exacerbating, or intensifying the experience and symptoms of post-traumatic stress disorder (PTSD), compulsive cravings, eating disorders such as anorexia nervosa and bulimia nervosa, spastic hemiplegia, incapacitation following a stroke or cerebrovascular accident, restricted cognitive function and motor control due to multiple sclerosis, social anxiety or phobia, bipolar disorder, schizophrenia, attention deficit hyperactivity disorder, and depression.
Example conditions aggravated by mental imagery
The aforementioned challenges and difficulties are some of those for which there is evidence to show that an individual can aggravate the symptoms and intensify the pain or distress precipitated by the condition through generating mental imagery that emphasizes its severity.
The following elaborates the way in which such mental imagery contributes to or aggravates four specific conditions:
Posttraumatic stress disorder
Social anxiety
Depression
Bipolar disorder
Posttraumatic stress disorder
Posttraumatic stress disorder often proceeds from experiencing or witnessing a traumatic event involving death, serious injury, or significant threat to others or oneself; and disturbing intrusive images, often described by the patient as 'flashbacks', are a common symptom of this condition across demographics of age, gender, and the nature of the precipitating traumatic event. This unbidden mental imagery is often highly vivid, and provokes memories of the original trauma, accompanied by heightened emotions or feelings and the subjective experience of danger and threat to safety in the present "here and now".
Social anxiety
Individuals with social anxiety have a higher than normal tendency to fear situations that involve public attention, such as speaking to an audience or being interviewed, meeting people with whom they are unfamiliar, and attending events of an unpredictable nature. As with posttraumatic stress disorder, vivid mental imagery is a common experience for those with social anxiety, and often comprises images that revive and replay a previously experienced stressful, intimidating or harrowing event that precipitated negative feelings, such as embarrassment, shame, or awkwardness. Thereby, mental imagery contributes to the maintenance and persistence of social anxiety, as it does with posttraumatic stress disorder.
In particular, the mental imagery commonly described by those suffering from social anxiety often comprises what cognitive psychologists describe as an "observer perspective". This consists of an image of themselves, as though from an observing person's perspective, in which those suffering from social anxiety perceive themselves negatively, as if from that observing person's point of view. Such imagery is also common among those suffering from other types of anxiety, who often have depleted ability to generate neutral, positive, or pleasant imagery.
Depression
The capacity to evoke pleasant and positively affirming imagery, either voluntarily or involuntarily, may be a critical requisite for precipitating and sustaining positive moods or feelings and optimism; and this ability is often impaired in those suffering from depression. Depression consists of emotional distress and cognitive impairment that may include feelings of hopelessness, pervasive sadness, pessimism, lack of motivation, social withdrawal, difficulty in concentrating on mental or physical tasks, and disrupted sleep.
Whilst depression is frequently associated with negative rumination of verbal thought patterns manifested as unspoken inner speech, ninety percent of depressed patients reporting distressing intrusive mental imagery that often simulates and recollect previous negative experiences, and which the depressed person often interprets in a way that intensifies feelings of despair and hopelessness. In addition, people suffering from depression have difficulty in evoking prospective imagery indicative of a positive future. The prospective mental imagery experienced by depressed persons when at their most despairing commonly includes vivid and graphic images related to suicide, which some psychologists and psychiatrists refer to as "flash-forwards".
Bipolar disorder
Bipolar disorder is characterized by manic episodes interspersed with periods of depression; 90% of patients experience comorbid anxiety disorder at some stage; and there is a significant prevalence of suicide amongst sufferers. Prospective mental imagery indicative of hyperactivity or mania and hopelessness contributes to the manic and depressive episodes respectively in bipolar disorder.
Principles
The therapeutic use of guided imagery, as part of a multimodal treatment plan incorporating other suitable methods, such as guided meditation, receptive music therapy, and relaxation techniques, as well as physical medicine and rehabilitation, and psychotherapy, aims to educate the patient in altering their mental imagery, replacing images that compound pain, recollect and reconstruct distressing events, intensify feelings of hopelessness, or reaffirm debilitation, with those that emphasize physical comfort, functional capacity, mental equanimity, and optimism.
Whether the guided imagery is provided in person by a facilitator, or delivered via media, the verbal instruction consists of words, often pre-scripted, intended to direct the participant's attention to imagined visual, auditory, tactile, gustatory or olfactory sensations that precipitate a positive psychologic and physiologic response that incorporates increased mental and physical relaxation and decreased mental and physical stress.
Guided imagery is one of the means by which therapists, teachers, or practitioners seek to achieve this outcome, and involves encouraging patients or participants to imagine alternative perspectives, thoughts, and behaviors, mentally rehearsing strategies that they may subsequently actualize, thereby developing increased coping skills and ability.
Stages
According to the computational theory of imagery, which is derived from experimental psychology, guided imagery comprises four phases:
Image generation
Image maintenance
Image inspection
Image transformation
Image generation
Image generation involves generating mental imagery, either directly from sensory data and perceptual experience, or from memory, or from fantasy.
Image maintenance
Image maintenance involves the volitional sustaining or maintaining of imagery, without which, a mental image is subject to rapid decay with an average duration of only 250 ms. This is because volitionally created mental images usually fade rapidly once generated in order to avoid disrupting or confusing the process of ordinary sensory perception.
The natural brief duration of mental imagery means that the active maintenance stage of guided imagery, which is necessary for the subsequent stages of inspection and transformation, requires cognitive concentration of attention by the participant. This concentrative attentional ability can be improved with the practice of mental exercises, including those derived from guided meditation and supervised meditative praxis. Even with such practice, some people can struggle to maintain a mental image "clearly in mind" for more than a few seconds; not only for imagery created through fantasy but also for mental images generated from both long-term memory and short-term memory.
In addition, while the majority of the research literature has tended to focus on the maintenance of visual mental images, imagery in other sensory modalities also necessitates a volitional maintenance process in order for further inspection or transformation to be possible.
The requisite for practice in sustaining attentional control, such that attention remains focused on maintaining generated imagery, is one of the reasons that guided meditation, which supports such concentration, is often integrated into the provision of guided imagery as part of the intervention. Guided meditation assists participants in extending the duration for which generated mental images are maintained, providing time to inspect the imagery, and proceed to the final transformation stage of guided imagery.
Image inspection
Once generated and maintained, a mental image can be inspected to provide the basis for interpretation, and transformation. For visual imagery, inspection often involves a scanning process, by which the participant directs attention across and around an image, simulating shifts in perceptual perspective.
Inspection processes can be applied both to imagery created spontaneously, and to imagery generated in response to scripted or impromptu verbal descriptions provided by the facilitator.
Image transformation
Finally, with the assistance of verbal instruction from the guided imagery practitioner or teacher, the participant transforms, modifies, or alters the content of generated mental imagery, in such a way as to substitute images that provoke negative feelings, are indicative of suffering, or that reaffirm disability or debilitation for those that elicit positive emotion, and are suggestive of resourcefulness, ability to cope, and an increased degree of mental and physical capacity.
This process shares principles with those that inform the clinical psychology techniques of "imagery restructuring" or "imagery re-scripting" as used in cognitive behavioral therapy.
While the majority of research findings on image transformation relate to visual mental imagery, there is evidence to support transformations in other sensory modalities such as auditory imagery. and haptic imagery.
Outcome of image generation, maintenance, inspection, and transformation
Through this technique, a patient is assisted in reducing the tendency to evoke images indicative of the distressing, painful, or debilitative nature of a condition, and learns instead to evoke mental imagery of their identity, body, and circumstances that emphasizes the capacity for autonomy and self-determination, positive proactive activity, and the ability to cope, whilst managing their condition.
As a result, symptoms become less incapacitating, pain is to some degree decreased, while coping skills increase.
Requisite for absorption
In order for the foregoing process to take place effectively, such that all four stages of guided imagery are completed with therapeutic beneficial effect, the patient or participant must be capable of or susceptible to absorption, which is an "openness to absorbing and self-altering experiences". This is a further reason why guided meditation or some form of meditative praxis, relaxation techniques, and meditation music or receptive music therapy are often combined with or form an integral part of the operational and practical use of the guided imagery intervention. For, all those techniques can increase the participant's or patient's capacity for or susceptibility to absorption, thereby increasing the potential efficacy of guided imagery.
As a mind-body intervention
The United States National Center for Complementary and Integrative Health (NCCIH), which is among twenty-seven organizations that make up the National Institutes of Health (NIH), classifies guided imagery and guided meditation, as mind–body interventions, one of five domains of medical and health care systems, practices, and products that are not presently considered part of conventional medicine.
The NCCIH defines mind-body interventions as those practices that "employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms", and include guided imagery, guided meditation and forms of meditative praxis, hypnosis and hypnotherapy, prayer, as well as art therapy, music therapy, and dance therapy.
All mind–body interventions, including the aforementioned, focus on the interaction between the brain, body, and behavior and are practiced with intention to use the mind to alter physical function and promote overall health and wellbeing.
There are documented benefits of mind-body interventions derived from scientific research firstly into their use in contributing to the treatment a range of conditions including headaches, coronary artery disease and chronic pain; secondly in ameliorating the symptoms of chemotherapy-induced nausea, vomiting, and localised physical pain in patients with cancer; thirdly in increasing the perceived capacity to cope with significant problems and challenges; and fourthly in improving the reported overall quality-of-life. In addition, there is evidence supporting the brain and central nervous system's influence on the immune system and the capacity for mind-body interventions to enhance immune function outcomes, including defense against and recovery from infection and disease.
Guided imagery has also demonstrated efficacy in reducing postoperative discomfort as well as chronic pain related to cancer, arthritis, and physical injury. Furthermore, the non-clinical uses for which the efficacy of guided imagery has been shown include managing the stress of public performance among musicians, enhancing athletic and competitive sports ability, and training medical students in surgical skills. The evidence that it is effective for non-musculoskeletal pain is encouraging but not definitive.
Evidence and explanation
Evidence and explanations for the effectiveness and limitations of creative visualization come from two discreet sources: cognitive psychology and psychoneuroimmunology.
Cognitive psychology
Guided imagery is employed as an adjunctive technique to psychological therapies in the treatment of many conditions, including those identified in the previous sections. It plays a significant role in the application of cognitive approaches to psychotherapy, including cognitive behavioral therapy, rational emotive behavior therapy, schema therapy, and mindfulness-based cognitive therapy.
These therapies derive from or draw substantially upon a model of mental functioning initially established by Aaron T. Beck, a psychiatrist and psychoanalyst who posited that the subjective way in which people perceive themselves and interpret experiences influences their emotional, behavioral, and physiological reactions to circumstances. He additionally discovered that by assisting patients in correcting their misperceptions and misinterpretations, and aiding them in modifying unhelpful and self-deprecating ways of thinking about themselves and their predicament, his patients had more productive reactions to events, and developed a more positive self-concept, self-image, or perception of themselves.
This use of guided imagery is based on the following premise. Everyone participates in both the voluntary and involuntary spontaneous generation of visual, auditory and other mental images, which is a necessary part of the way in which a person solves problems, recollects the past, predicts and plans the future, and formulates their self-perception, self-image, or the way they 'view' and perceive themselves.
However, this self-image can be altered and self-regulated with the aid of mind-body interventions including guided imagery, by which an individual changes the way he or she visualizes, imagines, and perceives themselves generally, and their physical condition, body image, and mental state specifically.
Psychoneuroimmunology
The term "psychoneuroimmunology" was coined by American psychologist Robert Ader in 1981 to describe the study of interactions between psychological, neurological, and immune systems.
Three years later, Jean Achterberg published a book called Imagery in Healing that sought to relate and correlate contemporaneous evidence from the then emerging scientific study of the way mental processes influence physical and physiological function, with particular emphasis on mental imagery, to the folklore she extrapolated from a set of diverse ancient and geographically indigenous practices previously described as 'shamanism' by the historian of religion and professor at the University of Chicago, Mircea Eliade; and a number of anthropologists and ethnologists.
The fundamental hypothesis of psychoneuroimmunology is concisely that the way people think and how they feel directly influences the electrochemistry of the brain and central nervous system, which in turn has a significant influence on the immune system and its capacity to defend the body against disease, infection, and ill health. Meanwhile, the immune system affects brain chemistry and its electrical activity, which in turn has a considerable impact on the way we think and feel.
Because of this interplay, a person's negative thoughts, feelings, and perceptions, such as pessimistic predictions about the future, regretful ruminations upon the past, low self-esteem, and depleted belief in self-determination and a capacity to cope can undermine the efficiency of the immune system, increasing vulnerability to ill health. Simultaneously, the biochemical indicators of ill health monitored by the immune system feeds back to the brain via the nervous system, which exacerbates thoughts and feelings of a negative nature. That is to say, we feel and think of ourselves as unwell, which contributes to physical conditions of ill health, which in turn cause us to feel and think of ourselves as unwell.
However, the interplay between cognitive and emotional, neurological, and immunological processes also provides for the possibility of positively influencing the body and enhancing physical health by changing the way we think and feel. For example, people who are able to deconstruct the cognitive distortions that precipitate perpetual pessimism and hopelessness and further develop the capacity to perceive themselves as having a significant degree of self-determination and capacity to cope are more likely to avoid and recover from ill health more quickly than those who remain engaged in negative thoughts and feelings.
This simplification of a complex interaction of interrelated systems and the capacity of the mind to influence the body does not account for the significant influence that other factors have on mental and physical well-being, including exercise, diet, and social interaction.
Nonetheless, in helping people to make such changes to their habitual thought processes and pervasive feelings, mind-body interventions, including creative visualization, when provided as part of a multimodal and interdisciplinary treatment program of other methods, such as cognitive behavioral therapy, have been shown to contribute significantly to treatment of and recovery from a range of conditions.
In addition, there is evidence supporting the brain and central nervous system's influence on the immune system and the capacity for mind-body interventions to enhance immune function outcomes, including defense against and recovery from infection and disease.
See also
Creative visualization
Guided meditation
Mental image
Psychoneuroimmunology
Tulpa
References
Hypnosis
Mind–body interventions
Psychotherapy by type
Imagination
Alternative medicine
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Supportive psychotherapy
|
Supportive psychotherapy is a psychotherapeutic approach that integrates various therapeutic schools such as psychodynamic and cognitive-behavioral, as well as interpersonal conceptual models and techniques.
The aim of supportive psychotherapy is to reduce or to relieve the intensity of manifested or presenting symptoms, distress or disability. It also reduces the extent of behavioral disruptions caused by the patient's psychic conflicts or disturbances. Unlike in psychoanalysis, in which the analyst works to maintain a neutral demeanor as a "blank canvas" for transference, in supportive therapy the therapist engages in a fully emotional, encouraging, and supportive relationship with the patient as a method of furthering healthy defense mechanisms, especially in the context of interpersonal relationships.
Supportive psychotherapy can be used as treatment for a variety of physical, mental, and emotional ailments, and consists of a variety of strategies and techniques in which therapists or other licensed professionals can treat their patients. The objective of the therapist is to reinforce the patient's healthy and adaptive patterns of thought behaviors in order to reduce the intrapsychic conflicts that produce symptoms of mental disorders.
Evolution of Supportive Psychotherapy
In the late 19th century, Sigmund Freud began to develop the techniques of psychoanalysis, which served as a foundation for all the other psychotherapeutic modalities. Freud found that by letting people talk freely about whatever came to mind (free association), they eventually revealed the origins of their psychological conflicts in disguised form. Upon hearing these confessions revealed through free association, the therapist would then interpret the unconscious cause for the patient's symptoms.
In the years following Freud's development of psychoanalysis, this approach was seen as the default in treating mental illness in patients. Psychotherapists faced the problem of patients who were unanalyzable: those without the reflective capacity to hear interpretations, or with “pseudoneurotic schizophrenia”. These patients who would react negatively to psychoanalysis would then receive a more bolstering, “supportive” treatment. This therapy, which would later be recognized as the initial stages of supportive psychotherapy, was not the preferred mode of treatment, not for the preferred patients, and hence, was seen as pejorative from the onset.
Franz Alexander studied Freud, and although he was trained in classical psychoanalytic technique, he began to evolve his own ideas about what allowed the curative process to occur in therapy.
Alexander noted that in classical psychoanalysis, the essential requirement for change was the insight the patient gained from interpretation of the transference neurosis. Alexander agreed with Freud that during psychoanalysis the patient underwent transference based on earlier life experience and emotional traumas. While Freud believed that the insight the patient gained from this was essential for healing to occur, Alexander felt the process of the patient feeling nurtured or comforted while reliving emotional traumas was also a curative force. He began to look at other factors that might be contributing to improvement, factors not related to insight but rather to the relationship of the patient with the psychoanalyst.
The objective of supportive psychotherapy was not to change the patient's personality but to help the patient cope with symptoms, prevent relapse of serious mental illness, or help a relatively healthy person deal with a crisis or transient problem. As defined in earlier years, supportive psychotherapy is a body of techniques, such as praise, advice, exhortation, and encouragement, embedded in psychodynamic understanding and used to treat severely impaired patients.
Over the next few decades and with ample studies to demonstrate efficacy, supportive psychotherapy gained momentum among professionals as a practical and efficacious method of therapy and supportive psychotherapy became recognized as the default treatment for patients with more severe psychological symptoms or those who couldn't withstand the rigors of psychoanalysis.
Context and History
Context
Supportive psychotherapy is often practiced for patients who are considered lower functioning, too fragile, or too unmotivated to participate in more demanding expressive therapy, which might have more chance of leading to personality change.
As a dyadic treatment that is characterized by use of direct measures to ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills, and psychological (ego) function, the treatment itself works to observe relationships (real or transferential) and both current and past patterns of emotional or behavioral response.
As supportive psychotherapy is introduced in environments less formal than a primary care office, supportive psychotherapy can appear as an expression of interest, attention to concrete services, encouragement and optimism. The relationship between the patient and the professional during supportive treatment exists solely to meet the needs of the patient, and it should not develop as a platonic relationship outside of professionalism.
History
Supportive psychotherapy functions with the objective of reducing anxiety and maintaining a positive patient-therapist relationship with minimal focus on transference. While this practice of therapy is seldom studied, it has since been identified and functions as an alternative to expressive therapy.
Supportive psychotherapy and supportive treatment works well for patients who are anticipated to fail at expressive therapy, or who are generally difficult to treat with expressive therapy.
An early documentation of supportive psychotherapy can be found in The Journal of Psychotherapy Practice and Research with contributions from David J. Hellerstein, M.D., Henry Pinsker, M.D., Richard N. Rosenthal, M.D., and Steven Klee, Ph.D. In their contributions to the study and exploration of supportive psychotherapy, These researchers note that with supportive and expressive falling on a continuum, the model for individual dynamic psychotherapy should be based on concepts from the supportive end of the continuum, rather than the expressive end.
A summary of Otto F. Kernberg's definition of supportive psychotherapy is featured in The Journal of Psychotherapy Practice and Research and defines what supportive therapy does rather than what it is. Kernberg's definition includes actions like:
reducing behavioral dysfunctions
reducing subjective mental distress
supporting and enhancing the patient's strengths, coping skills, and capacity to use environmental supports
maximizing treatment autonomy
facilitating maximum possible independence from psychiatric illness.
Uses
Supportive psychotherapy has been shown to be effective in a variety of psychiatric conditions including schizophrenia, bipolar disorder, depression, anxiety disorders, personality disorders, substance use disorders, eating disorders, and postpartum depression.
Supportive psychotherapy has also shown to be effective in a variety of medical conditions including breast cancer, ovarian cancer, diabetes, leukemia, heart disease, chronic bronchitis, emphysema, inflammatory bowel disease, back pain, and for hemodialysis patients.
Additionally, supportive therapy is recognized as the treatment of choice for patients seen by psychiatrists and residents who are suffering from extra-psychic problems, such as poverty, social and political oppression, and abuses of power in relationships that threaten to overwhelm their coping capacities.
Strategies and Techniques
Strategies and techniques associated with supportive psychotherapy include the following:
Listening
Argued by author John Battaglia as “the most powerful skill of supportive psychotherapy”, the element of listening in regards to supportive psychotherapy helps patients feel “heard” by their therapists or health professionals. Effective listening “includes careful attentiveness to the body language, emotional tone, and overall bearing of patients in the sessions.”
Plussing
Plussing is defined as “promoting a positive atmosphere in the therapy by finding the good in the patient and accentuating the positive in the patient’s situation.” Battaglia compares this supportive psychotherapy strategy to “putting on rose-colored glasses and seeing what the patient presents as half full,” and assisting patients with finding a positive outlook even if it appears difficult to find.
Explaining Behavior or Advice
Using the explaining behavior strategy within supportive psychotherapy allows for therapists and health professionals to lead patients to areas of comfort or security as they navigate complex and overwhelming emotions or compulsions. With this technique, the behavioral explanations brought forth by the professional should aim to make sense to the patient and help them feel supported.
Advice is another supportive psychotherapy strategy that branches from the explaining behavior technique. Advice is effective usually when the patient is able to connect it to their goals.
Confrontation and Reframing
Confrontation is essentially allowing the patient to reflect and comprehend how their patterns of behavior are contributing to their suffering. Therapists and professionals help guide patients to understanding how repeated behaviors or emotions contribute to their mental health and symptoms.
Reframing is related to the technique of confrontation as reframing involves looking at something in a different light or different angle and can provide patients with a new perspective as they undergo supportive psychotherapy.
Encouragement or Praise
Encouragement or Praise is often used in doses that are based on preexisting elements of the patient, such as their history, strengths, and weaknesses. Encouragement should be used sparingly in order to avoid the patient experiencing emotions of falling short to what their therapist expected of them. Using encouragement in this environment combines opportunities for education and movement in order to bring patients upward in their treatment or outside of their comfort zone.
Additionally, this technique can be used to reinforce accomplishments or positive changes in behavior, and can be positioned as the reinforcement of the patient's steps towards achieving their stated goals.
Hope
Very similarly to encouragement, hope is to be used sparingly and appropriately by therapists and health professionals in order to “provide enough hope for the patient to see change as a realistic opportunity.”
Metaphor
The use of metaphors is a stimulating element of supportive psychotherapy that “[utilizes] different parts of the patient’s brain than those stimulated by many of the other more language based techniques.” A metaphor is said to “stick” in a patient's head in a “very durable way.”
Coping Skills
Therapists and health professionals assisting patients with developing cognitive and behavioral coping skills is another technique used for supportive psychotherapy. These techniques range in complexity, and can consist of mantras or coping plans for the patient.
Self-soothing
Giving patients the tools necessary to develop self-soothing habits in opposition to unhealthy acting-out behavior, such as extreme mood swings, substance abuse, or acting out.
Creative Opportunities
Creative opportunities allow for therapists and health professionals to introduce their patients to creative outlets in order to express their emotions. Some of these techniques within this strategy include storytelling, journaling, and writing letters they won't send.
Some techniques identified, but generally avoided and used with caution are humor and comparing pain.
Studies on Supportive Psychotherapy
In an extensive longitudinal study developed in the 1950s, the "Menninger Psychotherapy Research Project" compared patients receiving psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy over a 23-year span. The main objective of the study was to critically examine the difference between psychoanalysis and psychoanalytic psychotherapy. The supportive psychotherapy arm of the study was placed more as a control condition than as a rigorous technique for comparison. The study results concluded there were no significant differences among the three different types of psychotherapy.
In one 1978 study looking at treatment of agoraphobia, mixed phobias, or simple phobias, patients were randomly assigned to one of three treatment conditions: behavior therapy alone, behavior therapy plus imipramine (medication) treatment, or supportive therapy plus imipramine (medication) treatment. Therapists in the behavior therapy groups used a manualized, highly structured treatment protocol that included relaxation training and systematic desensitization in imagination, specific in vivo desensitization homework assignments, and assertiveness training (including modeling, role playing, behavior rehearsal, and in vivo homework assignments). The supportive therapy was nondirective; patients took the initiative in all discussions. The therapists doing supportive therapy were instructed to be empathic and non-judgmental and to encourage patients to ventilate feelings and discuss problems, anxieties, and interpersonal relationships. The researchers found that there were no significant differences between the therapy conditions and that patients did well in both.
In a 2005 randomized controlled study looking at cognitive-behavioral therapy versus interpersonal therapy for anorexia nervosa, once again supportive psychotherapy was used as a control condition. In the cognitive-behavioral therapy arm of the study, the patients underwent several phases of treatment, including psychoeducation, motivational assessment, cognitive-behavioral skills (including thought restructuring and homework assignments), relapse prevention, and recovery strategies.
Teaching Supportive Psychotherapy
Researchers Arnold Winston, M.D., Richard N. Rosenthal, M.D., and Laura Weiss Roberts, M.D., M.A. express the elusiveness of the field of supportive psychotherapy: it is not based on “rigorous and internally consistent or appealing theory, it does not offer solutions to intractable clinical problems, and the field itself has no conferences, stars, and relatively few books.”
In Winston's Rosenthal's and Robert's text, “Learning Supportive Psychotherapy, Second Edition: An Illustrated Guide,” these authors note that “The psychotherapist’s central task is learning to understand...the emotional experience of the patient” (Balsam and Balsam), which was presented universally in regards to teaching supportive psychotherapy.
This universal treatment provided little guidance in how to handle patients who were inarticulate or poorly educated, who have intractable social problems, severe behavioral problems, or those who only visited for a couple months at a time or visited biweekly.
In 2012, Adam M. Brenner, M.D. advocated for a “much more sophisticated approach” to teaching health professionals and therapists about supportive psychotherapy, which focused on three important factors of supportive psychotherapy:
Its relevance for common factors underlying all forms of psychotherapy
Its role on a spectrum of psychodynamically informed psychotherapies
Its value as a modality that includes specifically definable techniques and aims
Brenner also advocated for “teaching supportive psychotherapy in diverse clinical rotations, including inpatient and consultation-liaison services as well as ambulatory settings.”
Criticism about supportive psychotherapy
As the method of supportive psychotherapy grew in popularity among psychologists and healthcare professionals, backlash concerning the effectiveness or validity of nonpsychoanalytic techniques arose. With psychoanalysis, the theory was that once a person improved through gaining insight, he or she underwent a permanent and curative change of personality. By contrast, changes brought about through more supportive types of psychotherapy were seen by critics as behavioral, meaning more transient and specific to the symptoms and not indicative of permanent personality change, which resulted in psychoanalysts believing that supportive-type therapy was not psychotherapy at all.
An additional criticism regarding supportive psychotherapy is that it addresses only problems and conflicts that the patient is aware of. Other types of psychotherapy rely on less direct measures, such as identifying unconscious conflicts. Supportive psychotherapy looks at abstract entities such as defense mechanisms only when they seem maladaptive.
See also
Phenomenology
Psychotherapy
Expressive therapies
Supportive communication
References
Psychotherapy by type
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Narcology
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Narcology (: ), from Russian нарко- (narco-, pertaining to narcotics, illicit drugs) + -логия (-logy, "branch of study") is a subspecialty of psychiatry dealing with the prevention, treatment, diagnosis, social care and recovery of drug-dependent persons. The study and science of phenomena of "narcomania", "toxicomania", chronic alcoholism, and its ætiology, pathogenesis, and clinical aspects. The term for a practitioner of narcology is narcologist. In the United States, the comparable terms are "addiction medicine" and "addictionist".
Narcology was introduced as a separated medical specialty in the Soviet Union during the early 1960s through the 1970s. The term "narcology" is used especially in the countries of the former Soviet Union, including Russia.
Human right violations in Russia
United Nations bodies and human rights organizations have documented human rights violations against people who use drugs in Russia, including the absolute prohibition on opioid substitution therapy and methadone maintenance treatment, the use of unscientific methods in the treatment of addictive disorders, the absence of drug dependence treatment for people with serious medical conditions.
See also
Addiction psychiatry
Addiction medicine
Further literature
References
Sources
Addiction medicine
Addiction psychiatry
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Got the morbs
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"Got the morbs" is a slang phrase or euphemism used in the Victorian era. The phrase describes a person afflicted with temporary melancholy or sadness. The term was defined in James Redding Ware's 1909 book Passing English of the Victorian Era.
Etymology and history
Morbs is a slang abstract noun that is derived from the adjective morbid. The word morbid came from the original Latin word , which meant 'sickly', 'diseased' or 'unwholesome'. The word also has roots in the Latin word , which meant 'sorrow', 'grief', or 'distress of the mind'. The phrase appeared in the book Passing English of the Victorian Era (1909) by James Redding Ware. The book states that the phrase dates from 1880 and defines it: "Temporary melancholia. Abstract noun coined from adjective morbid." The British lexicographer Susie Dent described "having the morbs" as "to sit under a cloud of despondency".
Popular culture
In 2015, the Boston-based indie rock band the Sheila Divine released a full-length album titled The Morbs. An all-girl band in Lincoln, Nebraska, named themselves the Morbs after the phrase.
See also
Depression in childhood and adolescence
Depression (mood)
Existential crisis
Feeling
Melancholia
Mixed anxiety–depressive disorder
References
External links
Euphemisms
Colloquial terms
British slang
Victorian era
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Brief resolved unexplained event
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Brief resolved unexplained event (BRUE), previously apparent life-threatening event (ALTE), is a medical term in pediatrics that describes an event that occurs during infancy. The event is noted by an observer, typically the infant's caregiver. It is characterized by one or more concerning symptoms such as change in skin color, lack of breathing, weakness, or poor responsiveness. By definition, by the time they are assessed in a healthcare environment they must be back to normal without obvious explanation after the clinician takes the appropriate clinical history and physical examination.
The American Academy of Pediatrics (AAP) clarified the use of both terms in a 2016 consensus statement that recommended the term BRUE be used whenever possible as it is more specifically defined. Thus, it is more useful for assessing risk of further events. The cause for BRUEs is often unknown, although some of the more common causes include gastroesophageal reflux, seizure, and child maltreatment. Evaluation after an ALTE or BRUE is diagnostically important, as some events represent the first sign or symptom of an underlying medical condition. In most cases, assuming the infants are otherwise healthy and no underlying medical issue is found, the infants who have a BRUE are unlikely to have a second event and have an even smaller risk of death.
Presentation
A BRUE is a description of a self-limited episode. Usually a BRUE lasts for less than 1 minute. By definition, the episode must have resolved by the time the infant is evaluated by a medical professional. The caregiver may report observation of bluish skin discoloration, called cyanosis. Breathing abnormalities, such as lack of breathing, slow breathing, or irregular breathing may be noted. Differences in muscle tone, such as transient floppiness or rigidity can also be characterized as a BRUE. Changes in level of responsiveness such as abnormal eye contact or inability to interact can also fulfill the classification.
A BRUE is a term used by a clinician to characterize an infant's self-limited episode witnessed by someone else. The AAP defines a BRUE as a sudden, brief episode that occurs to infants less than 1 year of age, lasts less than one minute, and resolves completely on its own prior to being evaluated by a health professional. The event must include at least one of the following:
skin color change to blue (cyanosis) or pale (pallor)
abnormal breathing
muscle weakness
decreased responsiveness
Causes
Most infants who have a BRUE are never diagnosed with a definitive cause for the event. However, we use the literature on ALTEs, which is more extensive, to help explain the cause of a BRUE. These causes may also be considered conditions that can be confused with a BRUE.
Gastroesophageal reflux
Vomiting or choking during feeding can trigger laryngospasm that leads to a BRUE or ALTE. This is a likely cause if the infant had vomiting or regurgitation just prior to the event, or if the event occurred while the infant was awake and lying down. In healthy infants with a suggestive GER event, no additional testing is typically done. In infants with repeated episodes of choking or repeated acute events, evaluation with a swallowing study can be helpful.
Other causes
Other causes that are less common include meningitis, urinary tract infection, breath-holding spells, congenital central hypoventilation syndrome, cancer, intracranial bleed, apnea of infancy, periodic breathing of infancy, choking, obstructive sleep apnea, factitious disorder imposed on another (formerly Munchausen syndrome).
Diagnosis
Taking the history of the event is vital in the evaluation of a BRUE. The first step is determining whether this is truly a BRUE by looking for presence of abnormal symptoms or vital signs. If this is the case, then it cannot be labelled as a BRUE and the healthcare professional should treat accordingly.
Low-risk infants
The next step in evaluation is distinguishing whether this BRUE is low- or high-risk. The American Academy of Pediatrics classifies an infant as low risk if they have a BRUE and meet the following characteristics:
infant is of age greater than 60 days
gestational age greater than or equal to 32 weeks
infant has had no prior BRUEs
this BRUE did not occur in a cluster
cardiopulmonary resuscitation (CPR) by a medical provider was not required
no concerning features on history
no concerning physical examination findings
duration less than 20 seconds
High-risk infants
If the infant does not meet all of these criteria, the BRUE is considered high-risk, and more likely represents an underlying medical condition. Characteristics of the infant that make this more likely include history of similar events or clustering, history of unexpected death in a sibling, need for CPR by a trained medical professional, ongoing lethargy, suspicion for child abuse or maltreatment, or existence of genetic syndrome or congenital anomalies.
Management
If the infant meets criteria for a low-risk BRUE and the clinician feels there are no concerning findings otherwise, treatment often involves simple short observation in the emergency department with pulse oximetry. For the cases where parents complain of specific symptoms at the time of the event, then follow-up testing may be done for the related conditions or diseases. Other tests are not typically recommended for low-risk infants.
For infants that have concerning features on history or physical, and are thus categorized as high-risk, further evaluation is warranted. This will vary greatly depending on the infants symptoms, but may include, urinalysis, complete blood count, imaging with chest x-ray, and laboratory screening for ingestion of medications or poisons. Also, for infants in the high-risk category, clinicians should consider admission to the hospital for extended observation, depending on the benefits and risk of the case. The course of the admission provides an opportunity to witness a second event to better characterize it and narrow the list of possible diagnoses. The observation of infants at home with the help of medical devices after discharge is not recommended.
Prognosis
The risk of death of patients who have a BRUE has been studied by using the literature about ALTEs, since this data is more abundant. The studies concluded that there is no increased risk of death for these patients compared to the rest of the infant population. As for the prognosis of these infants into adulthood, research still needs to be conducted to assess for any long-term health effects.
History
In 1986, the National Institute of Health defined an apparent life-threatening event (ALTE ) as an observed frightening event of an infant that includes at least one component of lack of breathing (apnea), skin color change (such as cyanosis), weakness, choking, or gagging. The term was invented to avoid previously used terms such as "near-miss SIDS" to dissociate the event from SIDS, a separate condition in infancy. There had been literature discussion in the past about the increased risk of SIDS in these infants, but more recently the research has concluded that there is no direct relationship between an ALTE and SIDS. It also was defined as part of an attempt to characterize the different forms of apnea, or sudden lack of breathing, in infants.
In 2016, the American Academy of Pediatrics (AAP) published a clinical practice guideling recommending the replacement of ALTE with a new term, brief resolved unexplained event (BRUE). The guidelines state that the term ALTE is still applicable with key differences between ALTE and BRUE. The biggest difference is whether the infant is symptomatic at time of presentation to a health professional. If the infant is still showing symptoms, then the condition is termed an ALTE. In order to be considered a BRUE, the infant should be completely asymptomatic at time of presentation, which is more common. Because of this, a BRUE can also be considered as a subset of ALTE. The term change was also recommended in large part due to the "life-threatening" suggestion from the older term. The rate of death in infants following a BRUE has been studied and is relatively rare, about 1 in 800.
References
External links
Children's health
Pediatrics
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Historical institutionalism
|
Historical institutionalism (HI) is a new institutionalist social science approach that emphasizes how timing, sequences and path dependence affect institutions, and shape social, political, economic behavior and change. Unlike functionalist theories and some rational choice approaches, historical institutionalism tends to emphasize that many outcomes are possible, small events and flukes can have large consequences, actions are hard to reverse once they take place, and that outcomes may be inefficient. A critical juncture may set in motion events that are hard to reverse, because of issues related to path dependency. Historical institutionalists tend to focus on history (longer temporal horizons) to understand why specific events happen.
The term "Historical Institutionalism" began appearing in publications in the early 1990s, although it had been used in the late 1980s. The most widely cited historical institutionalist scholars are Peter Hall, Paul Pierson, Theda Skocpol, Douglass North, and Kathleen Thelen. Prominent works of historical institutionalist scholarship have used both sociological and rationalist methods. Due to a focus on events involving causal complexity (equifinality, complex interaction effects and path dependency), historical institutionalist works tend to employ detailed comparative case studies.
Old and new institutionalism
Kathleen Thelen and Sven Steinmo contrast New Institutionalism with "Old Institutionalism", which was overwhelmingly focused on detailed narratives of institutions, with little focus on comparative analyses. Thus, the Old Institutionalism was unhelpful for comparative research and explanatory theory. This "Old Institutionalism" began to be undermined when scholars increasingly highlighted how the formal rules and administrative structures of institutions were not accurately describing the behavior of actors and policy outcomes.
Works, such as Karl Polanyi's The Great Transformation, Theda Skocpol's States and Social Revolutions, Philippe Schmitter's Still a Century of Corporatism?, Barrington Moore's Social Origins of Dictatorship and Democracy, and Evans, Ruschemeyer and Skocpol's Bringing the State Back In have been characterized as precursors to Historical Institutionalism, spawning a new research program.
Historical institutionalism is a predominant approach in research on the welfare state. In the field of International Relations, John Ikenberry's After Victory and Abraham Newman's Protectors of Privacy are prominent works of historical institutionalist scholarship.
The treatment of history
Unlike most western scholars who preceded them, including classical liberals, classical Marxists, empiricists, dialectical thinkers and positivists, historical institutionalists do not accept that history necessarily develops in a straightforward, linear fashion. Instead, they examine the conditions under which a particular trajectory was followed and not others, a phenomenon that Gabriel Almond refers to as the "historical cure". As a consequence, specifying why particular paths were not taken is as important as specifying the actual trajectory of history.
As opposed to the old institutionalists, they postulate that history will not necessarily lead to a "happy" outcome (i.e. "fascism or democracy as the end of history").
Historical institutionalist works tend to reject functionalist accounts of institutions. Therefore, they are suspicious of explanations for the emergence of institutions that work backwards from the functions of institutions to their origins. Historical institutionalists tend to see origins behind the creation of institutions as the result of conflict and contestation, which then gets locked in and persists, even if the circumstances that resulted in the institution change.
Mechanisms of institutional stability
The concept of path dependence is essential to historical institutionalist analyses. Due to path dependence, institutions may have considerable stability and "stickiness", even in situations when the institutional leads to suboptimal arrangements. For Paul Pierson, path dependence entails that “outcomes at a ‘critical juncture’ trigger feedback mechanisms [negative or positive] that reinforce the recurrence of a particular pattern into the future.” Thus, path dependence makes it harder to reverse once a certain path has been taken, because there are increased costs to switching from the path. These paths may lead to outcomes are inefficient, but nonetheless persist, because of the costs involved in making substantial overhauls. An example of this is the QWERTY keyboard layout, which was efficient for typewriters to prevent jams in the 19th century and was implemented in computer keyboards in the 20th century. However, the QWERTY keyboard is arguably not as efficient as a computer keyboard could be, but the keyboard layout has persisted over time due to the costs involved in overhauling computer keyboards. Jacob Hacker and Paul Pierson argue that other approaches to institutions may fall guilty of treating politics as if it were the film Groundhog Day where each day the participants just start over; in reality, past politics and policy legacies shape the interests, incentives, power and organizational abilities of political actors.
According to Paul Pierson, the following factors contribute to institutional stability:
Large setup costs: actors may stick with existing institutions because there are large setup costs associated with creating new ones
Learning effects: actors may stick with existing institutions because it is costly to learn about procedures and processes in new institutions
Coordination effects: actors may stick with existing institutions because it is too complex to coordinate multiple actors into creating new institutions
Adaptive expectations: actors may expend resources on an institution over another because it is likely to stay or become the dominant institution
These factors entail that actors have devoted resources into developing certain institution-specific skills and are unlikely to expend resources on alternative institutions.
A related crux of historical institutionalism is that temporal sequences matter: outcomes depend upon the timing of exogenous factors (such as inter-state competition or economic crisis) in relation to particular institutional configurations (such as the level of bureaucratic professionalism or degree of state autonomy from class forces). For example, Theda Skocpol suggests that the democratic outcome of the English Civil War was a result of the fact that the comparatively weak English Crown lacked the military capacity to fight the landed upper-class. In contrast, the rise of rapid industrialization and fascism in Prussia when faced with international security threats was because the Prussian state was a “highly bureaucratic and centralized agrarian state” composed by “men closely ties to landed notables”. Thomas Ertman, in his account of state building in medieval and early modern Europe, argues that variations in the type of regime built in Europe during this period can be traced to one macro-international factor and two historical institutional factors. At the macro-structural level, the “timing of the onset of sustained geopolitical competition” created an atmosphere of insecurity that appeared best addressed by consolidating state power. The timing of the onset of competition is critical for Ertman's explanation. States that faced competitive pressures early had to consolidate through patrimonial structures, since the development of modern bureaucratic techniques had not yet arrived. States faced with competitive pressures later on the other hand, could take advantage of advancements in training and knowledge to promote a more technically oriented civil service.
An important element to historical institutionalism is that it may cement certain distributions of power or increase asymmetries of power through policy feedbacks, "lock in" effects and stickiness. For example, France has a permanent seat on the UN Security Council because of its power and status at the end of World War II, yet it would likely not get a permanent seat if the UN Security Council were re-designed decades later.
Mechanisms of institutional change
Historical institutionalists have identified major shocks, such as wars and revolutions, as important factors that lead to institutional change because those shocks create "critical junctures" whereby certain path dependencies get created. One prominent account in this vein is John Ikenberry's work on international orders which argues that after major wars, the dominant powers set up world orders that are favorable to their interests.
Aside from shocks, historical institutionalists have also identified numerous factors that subtly lead to institutional change. These include:
Layering: grafting new rules onto old rules
Displacement: when relevant actors leave existing institutions and go to new or alternative institutions
Conversion: old rules are reinterpreted and redirected to apply to new goals, functions and purposes
Drift: old rules fail to apply to situations that they were intended for because of changing social conditions
Exhaustion: an institution overextends itself to the point that it does not have the capacity to fulfill its purposes and ultimately breaks down
As part of these subtle changes, there may be widespread noncompliance with the formal rules of an institution, prompting change. There may also be shifts in the balance of power between the social coalitions that comprise the institution.
Reception
Historical institutionalism is not a unified intellectual enterprise (see also new institutionalism). Some scholars are oriented towards treating history as the outcome of rational and purposeful behavior based on the idea of equilibrium (see rational choice). They rely heavily on quantitative approaches and formal theory. Others, more qualitative oriented scholars, reject the idea of rationality and instead emphasize the idea that randomness and accidents matter in political and social outcomes. There are unsolvable epistemological differences between both approaches. However given the historicity of both approaches, and given their focus on institutions, both can fall under "historical institutionalism".
Munck argues that work that emphasizes critical junctures as causes has two problems: (i) the problem of infinite regress (the notion that the cause of events can constantly be pushed back further in time), and (ii) the problem of distal non-recurring causes (convincingly arguing that a distant non-recurring event caused a much later event).
Avner Greif and David Laitin have criticized the notion of increased returns.
Sociological institutionalists and ideational scholars have criticized versions of Historical Institutionalism that adopt materialist and rationalist ontologies. Scholars who use ideational approaches argue that institutional change occurs during episodes when institutions are perceived be failing (such as during economic crises) or during episodes of uncertainty, as this creates room for an exchange of ideas and a receptivity for institutional change. Political scientists such as Henry Farrell, Martha Finnemore, Mark Blyth, Oddny Helgadóttir, and William Kring argue that Historical Institutionalism has over time tended to engage more with rational choice institutionalism than with sociological institutionalism. Vincent Pouliot similarly writes that "soft rational choice... informs most versions of [Historical Institutionalism]." According to Michael Zurn, Historical institutionalism "lacks a theory of action."
In Paradigms and Sand Castles, an influential book on research design in comparative politics, Barbara Geddes argues that there are methodological limits to the kind of path-dependent arguments that is often found in Historical Institutionalist research. She argues that it is hard to rule out rival explanations for a proposed outcome and to precisely identify one purported critical juncture or another.
Major institutionalist scholars and books
Perry Anderson, Lineages of the Absolutist State
Kenneth A. Armstrong & Simon Bulmer, The governance of the Single European Market
Reinhard Bendix, Nation Building and Citizenship: Studies of our Changing Social Order
Suzanne Berger, Peasants Against Politics
Ruth Berins Collier and David Collier, Shaping the Political Arena
Thomas Ertman, Birth of the Leviathan
Peter B Evans, Embedded Autonomy
Alexander Gerschenkron, Economic Backwardness in Historical Perspective
Peter A. Hall, Governing the Economy
Samuel P. Huntington, Political Order in Changing Societies
John Ikenberry, After Victory
Chalmers Johnson, Peasant Nationalism and Communist Power
Peter Katzenstein, Cultural Norms and National Security
Atul Kohli, The State and Development in the Third World
Stephen Krasner, Sovereignty: Organized Hypocrisy
Margaret Levi, Consent, Dissent and Patriotism
Gregory Luebbert, Liberalism Fascism and Social Democracy
Ian Lustick, Unsettled States, Disputed Lands
Joel S. Migdal, Strong Societies and Weak State
Barrington Moore, Social Origins of Dictatorship and Democracy
Douglass North, Institutions, Institutional Change and Economic Performance
Paul Pierson, Politics in Time
Karl Polanyi, The Great Transformation
Dietrich Rueschemeyer, Evelyne Huber, and John D. Stephens, Capitalist Development and Democracy
James C. Scott, Seeing Like a State
Theda Skocpol, States and Social Revolutions, Protecting Soldiers and Mothers
Philip Selznick, "Institutionalism 'Old' and 'New'". Administrative Science Quarterly 41 (2): 270–77
Stephen Skowronek, The Politics Presidents Make
Rogers Smith, Civic Ideals
Sven Steinmo, Taxation and Democracy, The Evolution of Modern States
Kathleen Thelen, How Institutions Evolve?
Charles Tilly, Coercion, Capital, and European States, AD 990–1992
Stephen Van Evera, Causes of War
Thorstein Veblen, An Inquiry into the Nature of Peace and the Terms of Its Perpetuation
Rorden Wilkinson, The WTO: Crisis and the Governance of Global Trade
Daniel Ziblatt, Structuring the State
John Zysman, Governments, Markets, and Growth: Financial Systems and Politics of Industrial Change.
Francis Fukuyama, The Origins of Political Order
See also
Critical juncture theory
Liberal institutionalism
Institutional economics
New institutional economics
Rational Choice Institutionalism
Analytic narrative
References
Further reading
Daniel W. Drezner (2010) "Is historical institutionalism bunk?" Review of International Political Economy, 17:4, 791–804
Peter A. Hall, “Historical Institutionalism in Rationalist and Sociological Perspective,” in James Mahoney and Kathleen Thelen, Explaining Institutional Change (Cambridge University Press 2010).
Pierson, Paul. 2000. "Path Dependence, Increasing Returns, and the Study of Politics." American Political Science Review 33, 6/7:251-67.
Fioretos, Orfeo (ed.). International Politics and Institutions in Time. Oxford University Press.
Fioretos, O. (2011). "Historical Institutionalism in International Relations." International Organization, 65(2), 367–399.
Fioretos, Orfeo, Tulia G. Falleti, and Adam Sheingate. 2016. The Oxford Handbook of Historical Institutionalism. Oxford University Press.
Steinmo, Sven. 2008. "Historical Institutionalism." in Approaches and Methodologies in the Social Sciences. Cambridge University Press.
Thelen, Kathleen. 2002. "How Institutions Evolve: Insights from Comparative-Historical Analysis." in Mahoney, James and Dueschemeyer, Dietrich, eds. Comparative Historical Analysis in the Social Sciences. Cambridge University Press.
Peter Hall and David Soskice. Varieties of Capitalism. Oxford: Oxford University Press. 2000.
Kathleen Thelen, “Historical Institutionalism in Comparative Politics.” Annual Review of Political Science 1999: 369–404.
Kathleen Thelen. "Varieties of Capitalism: Trajectories of Liberalization and the New Politics of Social Solidarity." Annual Review of Political Science. 2012; 15:137- 159.
Henry Farrell and Abraham Newman. Domestic Institutions Beyond the Nation State: Charting the New Interdependence Approach. 2014. World Politics 66, 2:331- 363.
Henry Farrell and Abraham L. Newman (2010) "Making global markets: Historical institutionalism in international political economy." Review of International Political Economy, 17:4, 609–638
Rixen, Thomas, Lora Anne Viola, Michael Zürn (eds.). 2016. Historical Institutionalism and International Relations: Explaining Institutional Development in World Politics. Oxford University Press.
Waylen, G. (2009). What Can Historical Institutionalism Offer Feminist Institutionalists? Politics & Gender, 5(2), 245–253.
Political science terminology
Subfields of political science
Institutionalism
Social science methodology
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Lujan–Fryns syndrome
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Lujan–Fryns syndrome (LFS) is an X-linked genetic disorder that causes mild to moderate intellectual disability and features described as Marfanoid habitus, referring to a group of physical characteristics similar to those found in Marfan syndrome. These features include a tall, thin stature and long, slender limbs. LFS is also associated with psychopathology and behavioral abnormalities, and it exhibits a number of malformations affecting the brain and heart. The disorder is inherited in an X-linked dominant manner, and is attributed to a missense mutation in the MED12 gene. There is currently no treatment or therapy for the underlying MED12 malfunction, and the exact cause of the disorder remains unclear.
Signs and symptoms
Intellectual disability in LFS usually ranges from mild to moderate, but severe cases have also been reported. A relatively common brain anomaly seen with LFS is agenesis of the corpus callosum, an error of embryonic development in which the corpus callosum (a structure of the mammalian brain composed of nerves that allows communication between the left and right cerebral hemispheres) is not present. Among a number of adverse neurological effects sometimes found with an absence of the corpus callosum, intellectual disability has been shown to occur at a rate of approximately 73 percent. A correlation between agenesis of the corpus callosum and intellectual disability in LFS, however, has not been suggested.
Psychiatric
Psychopathology and related behavioral abnormalities are typically seen in LFS, and they may be considered in the diagnosis of the disorder. The most common of these in LFS is an autism-like spectrum disorder, and LFS is considered one of a number of genetic disorders associated with autism. Additional alterations of psychopathology with behavioral manifestations that have been observed in LFS include: psychotic behavior, schizophrenia, hyperactivity and attention-deficit hyperactivity disorder, aggression, oppositional defiant disorder, obsessive compulsive disorder, extreme shyness, learning disability, cognitive impairment, short-term memory deficit, low frustration tolerance, social dysfunction, lack of impulse control, eating disorder and associated malnutrition, attributed to psychogenic loss of appetite; and pyromania.
While psychiatric conditions like these are to be expected with LFS, there have also been cases of the disorder with some preservation of mental and behavioral abilities, such as problem solving, reasoning and normal intelligence.
The psychopathology of LFS usually exhibits schizophrenia. When schizophrenia is diagnosed in an individual known to be affected by intellectual disability, LFS may be considered in the differential diagnosis of schizophrenia, with confirmation of cause through appropriate psychiatric and genetic evaluation methods.
Marfanoid habitus
LFS is clinically distinguished from other X-linked forms of intellectual disability by the accompanying presence of marfanoid habitus. Marfanoid habitus describes a group of physical features common to Marfan syndrome. Including Marfan syndrome and LFS, marfanoid features of this type have also been observed with several other disorders, one of which is multiple endocrine neoplasia type 2.
In LFS, specific features identified as marfanoid include: a long, narrow face; tall, thin stature; long, slender limbs, fingers and toes (not unlike arachnodactyly) with joint hyperextensibility, shortened halluces (the big toes) and long second toes.
The diagnosis of marfanoid habitus in LFS is often delayed because many of the physical features and characteristics associated with it are usually not evident until adolescence.
Head and face
Craniofacial and other features of LFS include: maxillary hypoplasia (underdevelopment of the upper jaw bone), a small mandible (lower jaw bone) and receding chin, a high-arched palate (the roof of the mouth), with crowding and misalignment of the upper teeth; macrocephaly (enlarged skull) with a prominent forehead, hypernasal speech (voice), a long nose with a high, narrow nasal bridge; a deep, short philtrum (the indentation in the upper lip, beneath the nose), low-set ears with some apparent retroversion, hypotonia (decreased muscle tone), pectus excavatum (a malformity of the chest), slightly enlarged to normal testicular size in males, and seizures.
Hypernasal speech, or "hypernasality", is primarily the result of velopharyngeal insufficiency, a sometimes congenital aberration in which the velopharyngeal sphincter allows too much air into the nasal cavity during speech. In LFS, hypernasality may also be caused by failure of the soft palate and uvula to reach the back wall of the pharynx (the interior cavity of the throat where swallowing generally occurs) during speech, a condition that can be associated with a submucosal cleft palate.
Heart
A number of features involving the heart have been noted in several LFS cases, the most significant being dilation of the aortic root, a section of the ascending aorta. Aortic root dilation (enlargement) is associated with a greatly increased risk of dissection of the aortic wall, resulting in aortic aneurysm. As this presents a possible life-threatening consequence of LFS, routine cardiac evaluation methods such as echocardiogram are implemented when the disorder is first diagnosed, along with MRI scans of the brain to screen for suspected agenesis of the corpus callosum. Additional effects on the heart that have been reported with LFS are ventricular and atrial septal defect.
Cause
A missense mutation in the MED12 gene, located on the human X chromosome, has been established as the cause of LFS. Missense mutations are genetic point mutations in which a single nucleotide in the genetic sequence is exchanged with another one. This leads to an erroneously substitution of a particular amino acid in the protein sequence during translation. The missense mutation in the MED12 gene, that causes LFS, is identified as p.N1007S. This indicates that the amino acid asparagine, normally located at position 1007 along the MED12 sequence, has been mistakenly replaced by serine. This mutation in MED12 causes incorrect expression and activity of the protein it encodes, resulting in the disorder.
Pathophysiology
MED12, or mediator of RNA polymerase II transcription, subunit 12 homolog of S. cerevisiae, is one of several subunits in the mammalian mediator complex, which regulates RNA polymerase II during mRNA transcription.
The Mediator complex is required for polymerase II transcription and acts as a bridge between the polymerase II enzyme and different gene-specific transcription factors. Mediator can contain up to 30 subunits, but some of the subunits are only required for regulation of transcription in particular tissues or cells. Currently, the exact mechanism by which dysfunction of MED12 results in LFS and its associated neuropsychopathic and physical characteristics is unclear. Marfanoid habitus, a highly arched palate and several other features of LFS can be found with Marfan syndrome, a connective tissue disorder. The finding of aortic root dilation in both disorders suggests that a mutation in an unspecified connective tissue regulating gene may contribute to the etiology of LFS.
A number of interesting experimental results have been obtained by studying MED12 mutations in the zebrafish, an animal model representing vertebrates. In zebrafish, a mutation in MED12 was found to be responsible for the mutant motionless (mot). Zebrafish with the mot mutation have neuronal and cardiovascular defects, although not all types of neurons are affected. Introduction of human MED12 mRNA into the zebrafish restores normal development. MED12 is also a critical coactivator for the gene SOX9, which is involved in the developmental regulation of neurons, cartilage and bone. In the zebrafish, MED12 defects cause maldevelopment of vertebrate embryonic structures such as the neural crest, which would alter function of the autonomic and peripheral nervous systems; and they also cause malformations of cell types serving as precursors to cartilage and bone, such as osteocytes. Some features found in LFS, like agenesis of the corpus callosum and cartilage-related craniofacial anomalies, are similar to defects found in zebrafish with MED12 and associated mutations.
Genetics
Lujan–Fryns syndrome is inherited in an X-linked dominant manner. This means the defective gene responsible for the disorder (MED12) is located on the X chromosome, and only one copy of the defective gene is sufficient to cause the disorder when inherited from a parent who has the disorder. Males are normally hemizygous for the X chromosome, having only one copy. As a result, X-linked dominant disorders usually show higher expressivity in males than females. This phenomenon is thought to occur with LFS.
As the X chromosome is one of the sex chromosomes (the other being the Y chromosome), X-linked
inheritance is determined by the karyotype of the parent carrying a specific gene and can often seem complex. This is because, typically, females have two copies of the X-chromosome, while males have only one copy. The difference between dominant and recessive inheritance patterns also plays a role in determining the chances of a child inheriting an X-linked disorder from their parentage.
In LFS, X-linked dominant inheritance was suspected, as boy and girl siblings in one family both exhibited the disorder. A scenario such as this would also be possible with X-linked recessive inheritance, but in this particular case report, the girl was believed to be a manifesting heterozygote carrying one copy of the mutated gene.
Sporadic cases of LFS, where the disorder is present in an individual with no prior family history of it, have also been reported in a small number of affected males.
Similarities to other genetic diseases
An individual exhibiting intellectual disability and other symptoms similar to LFS was found to have a terminal deletion of the subtelomeric region in the short arm of chromosome 5. Deletion of this area of chromosome 5 is associated with intellectual disability, psychotic behavior, autism, macrocephaly and hypernasal-like speech, as well as the disorder Cri du chat syndrome. Fryns (2006) suggests a detailed examination of chromosome 5 with FISH should be performed as part of the differential diagnosis of LFS.
Mutations in the UPF3B gene, also found on the X chromosome, are another cause of X-linked intellectual disability. UPF3B is part of the nonsense-mediated mRNA decay (NMD) complex, which performs mRNA surveillance, detecting mRNA sequences that have been erroneously truncated (shortened) by the presence of nonsense mutations. Mutations in UPF3B alter and prevent normal function of the NMD pathway, resulting in translation and expression of truncated mRNA sequences into malfunctioning proteins that can be associated with developmental errors and intellectual disability. Individuals from two families diagnosed with LFS and one family with FGS were found to have mutations in UPF3B, confirming that the clinical presentations of the different mutations can overlap.
Diagnosis
Although LFS is usually suspected when intellectual disability and marfanoid habitus are observed together in a patient, the diagnosis of LFS can be confirmed by the presence of the p.N1007S missense mutation in the MED12 gene.
Differential diagnosis
In the differential diagnosis of LFS, another disorder that exhibits some features and symptoms of LFS and is also associated with a missense mutation of MED12 is Opitz-Kaveggia syndrome (FGS). Common features shared by both LFS and FGS include X-linked intellectual disability, hyperactivity, macrocephaly, corpus callosum agenesis and hypotonia. Notable features of FGS that have not been reported with LFS include excessive talkativeness, consistent strength in socialization skills, imperforate anus (occlusion of the anus) and ocular hypertelorism (extremely wide-set eyes).
Whereas LFS is associated with missense mutation p.N1007S, FGS is associated with missense mutation p.R961W. As both disorders originate from an identical type of mutation in the same gene, while exhibiting similar, yet distinct characteristics; LFS and FGS are considered to be allelic. In the context of MED12, this suggests that the phenotype of each disorder is related to the way in which their respective mutations alter the MED12 sequence and its function.
Treatment
While there is no specific treatment for the underlying genetic cause of LFS, corrective procedures, preventive intervention measures, and therapies may be considered in the treatment and management of the many craniofacial, orthopedic, and psychiatric problems associated with the disorder. More pressing issues such as cardiac involvement or epileptic seizures should be routinely examined and monitored. Close attention and specialized follow-up care, including neuro-psychological evaluation methods and therapies, and special education, should be given to diagnose and prevent psychiatric disorders and related behavioral problems such as psychosis and outbursts of aggression.
Epidemiology
Lujan–Fryns syndrome is a rare X-linked dominant syndrome and is more common in males than females. Its prevalence within the general population has not yet been determined.
History
Lujan–Fryns syndrome is named after physicians J. Enrique Lujan and Jean-Pierre Fryns. The initial observation of suspected X-linked intellectual disability with Marfanoid features and craniofacial effects such as a high-arched palate was described by Lujan et al. in 1984. In the report, four affected male members of a large kindred (consanguinous family) were noted. Additional investigations of combined X-linked intellectual disability and Marfanoid habitus in other families, including two brothers, were reported by Fryns et al., beginning in 1987. The disorder soon became known as Lujan–Fryns syndrome.
See also
Fragile X syndrome
Aarskog syndrome
Coffin–Lowry syndrome
FG syndrome
References
Further reading
GeneReview/NIH/UW entry on MED12-Related Disorders
External links
Syndromes with craniofacial abnormalities
Syndromes with intellectual disability
X-linked dominant disorders
Syndromes affecting stature
Syndromes affecting the cardiovascular system
Rare syndromes
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Interpersonal and social rhythm therapy
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Interpersonal and social rhythm therapy (IPSRT) is an intervention for people with bipolar disorder (BD). Its primary focus is stabilizing the circadian rhythm disruptions that are common among people with bipolar disorder (BD). IPSRT draws upon principles from interpersonal psychotherapy, an evidence-based treatment for depression and emphasizes the importance of daily routine (rhythm).
IPSRT was developed by Ellen Frank, PhD at the University of Pittsburgh who published a book on her theories: Treating Bipolar Disorder, a Clinician's Guide to Interpersonal and Social Rhythm Therapy. Her research on IPSRT has shown that, in combination with medication, solving interpersonal problems and maintaining regular daily rhythms of sleeping, waking, eating, and exercise can increase quality of life, reduce mood symptoms, and help prevent relapse in people with BD.
Social Zeitgeber Hypothesis
Zeitgebers (“time givers”) are environmental cues that synchronize biological rhythms to the 24-hour light/dark cycle. As the sun is a physical zeitgeber, social factors are considered social zeitgebers. These include personal relationships, social demands, or life tasks that entrain circadian rhythms. Disruptions in circadian rhythms can lead to somatic and cognitive symptoms, as seen in jet lag or during daylight saving time. Individuals diagnosed with, or at risk for, mood disorders may be especially sensitive to these disruptions and thus, vulnerable to episodes of depression or mania when circadian rhythm disruptions occur.
Changes in daily routines place stress on the body's maintenance of sleep-wake cycles, appetite, energy, and alertness, all of which are affected during mood episodes. For example, depressive symptoms include disturbed sleep patterns (sleeping too much or difficulty falling asleep), changes in appetite, fatigue, and slowed movement or agitation. Manic symptoms include decreased need for sleep, excessive energy, and increase in goal-directed activity. When the body's rhythms becomes desynchronized, it can result in episodes of depression and mania.
Aims of Treatment
Goals of IPSRT are to stabilize social rhythms (e.g., eating meals with other people) while improving the quality of interpersonal relationships and satisfaction with social roles. Stabilizing social rhythms helps to protect against disruptions of biological rhythms; individuals are more likely to maintain a rhythm when other people are involved to hold them accountable.
Interpersonal work can involve addressing unresolved grief experiences including grief for the lost healthy self, negotiating a transition in a major life role, and resolving a role dispute with a significant other. These experiences can be disruptive to social rhythms and thus, serve as targets of treatment to prevent the onset and recurrence of mood episodes seen in bipolar disorder.
Phases of Treatment
IPSRT typically proceeds in four phases:
The initial phase involves a review of the patient's mental health history in order to elucidate patterns in the associations between social routine disruptions, interpersonal problems and affective episodes. Psychoeducation about BD and the importance of stable routines to mood maintenance is provided. Additionally, The Interpersonal Inventory is used to assess the quality of the patient's interpersonal relationships. One of four interpersonal problem areas is chosen to focus on:
Grief (e.g. loss of loved one, loss of healthy self)
Role transitions (e.g. married-to-divorced, parenthood)
Role disputes (e.g. conflict with spouse or parents)
Interpersonal deficits (e.g. persistent social isolation) The Social Rhythm Metric (SRM) is used to assess the regularity of social routines. Target and actual time of the following activities are tracked on a daily basis: got out of bed; first contact with another person; started work, school, or housework; ate dinner; and went into bed. The intensity of involvement with other people is also rated: 0 = alone, 1 = others present, 2 = others actively involved, and 3 = others very stimulating. Finally, mood is rated on a scale of -5 to +5 at the end of each day.
The intermediate phase focuses on bringing regularity to social rhythms and intervening in the interpersonal problem area of interest.
Social Rhythm Metric is heavily used to assess amount of activity being engaged in and the impact of activity on mood. The regularity (or irregularity) of activities is examined, and the patient and therapist collaboratively plan how to stabilize the daily routine by making incremental behavioral modifications until a regular target time at which these activities are done is achieved.
Sources of interpersonal distress are explored, and individuals in the patient's life who destabilize routine, along with those who are supportive, are identified. Frequency and intensity of social interactions, as well as other social rhythms (e.g. time at which returning home from school/work and then interacting with family), are discussed.
The maintenance phase aims to reinforce the techniques learned earlier in treatment in order to maintain social rhythms and positive interpersonal relationships.
Discussion of early warning signs of episodes are reviewed.
Symptomatic and functional change is monitored at each session by asking the patient to rate their mood and note any shifts in routine using the SRM.
The final phase involves termination in which sessions are gradually reduced in frequency.
Interpersonal Strategies
Once the interpersonal problem area of focus is chosen, the following strategies may be used:
Grief – This refers to symptoms resulting from incomplete mourning or unresolved feelings about the death of an important person. This can also refer to grief for the loss of a healthy self (i.e., the person before the illness or the person one could have become, if not for BD). Strategies include encouraging expression of painful feelings about lost hopes, ruined relationships, interrupted careers, and passed opportunities. This is followed by encouragement to develop new relationships, establish new, more realistic goals, and focus on future opportunities.
Interpersonal role disputes – This refers to any close relationship in which there are nonreciprocal expectations, such as in marital conflict and arguments with parental figures. Strategies include learning how to be more patient, tolerant, and accepting of limitations in self and others. This, in turn, can lead to fewer critical and argumentative instincts.
Role transition – This refers to any major life role change, such as new employment, graduation, retirement, marriage, divorce, and giving birth. This can also refer to the loss of previously pleasurable hypomania. Strategies can include noting the negative consequences of hypomania and encouraging the identification of rewarding life goals as suitable alternatives.
Interpersonal deficits – This refers to a long-standing history of impoverished or contentious social relationships, leading to an overall feeling of dissatisfaction. Strategies include identifying the common thread in the multiple disputes across one's life and possibly working to restore “burnt bridges”.
Social Rhythm Strategies
Individuals with BD benefit from a higher level of stability in their sleep and daily routines than those with no history of affective illness. It is important to identify situations in which routines can be thrown off balance, whether by excessive activity and overstimulation or lack of activity and under-stimulation. Once destabilizing triggers are identified, reasonable goals for change are established. Specific strategies include:
Encouraging proper sleep hygiene to introduce regularity to sleep-wake cycle
Establish a regular wake and sleep time
Avoid caffeine or other stimulants
Use the bed only for sleep and sex, not for watching TV, doing homework, reading etc.
Align sunlight exposure with wake time to help set circadian clock
Maintaining regular meal times throughout the day
Plan ahead by meal prepping the day before
Include snack times if needed to encourage consistent eating habits
Encouraging medication adherence and establishing a regular schedule
Use alarms on phone as reminders for when to take pills
Use daily pillboxes to keep track of which pills to take at certain times
Monitoring frequency and intensity of social interactions using Social Rhythm Metric
Note time at which interactions happen and adjust accordingly to establish regularity
Minimizing overstimulation of social interactions
Avoid frequent parties or events
Use recovery days as needed
Addressing under-stimulation with behavioral activation
Engage in activities that are pleasurable and that give one a sense of mastery
Focus on small, manageable goals that can lead to engagement in other activities (e.g., start jogging to get in shape prior to joining a basketball team)
Identifying interpersonal sources of stabilizing and destabilizing influence
Spend time with those who are supportive and stabilizing
Reduce time with those who are disruptive
Evidence of IPSRT Efficacy
In a randomized controlled trial, those who received IPSRT during the acute treatment phase went longer without a new affective episode (depression or mania) than those who received intensive clinical management. Participants in the IPSRT group also had higher regularity of social rhythms at the end of acute treatment, which was associated with reduced likelihood of relapse during maintenance phase. Additionally, those who received IPSRT showed more rapid improvement in occupational functioning than those assigned to intensive clinical management. However, at the end of two years of maintenance treatment, there were no differences between treatment groups.
IPSRT was studied as one of three intensive psychosocial treatments in the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). STEP-BD was a long-term outpatient study investigating the benefits of psychotherapies in conjunction with pharmacotherapy in treating episodes of depression and mania, as well as preventing relapse in people with bipolar disorder. Patients were 1.58 times more likely to be well in any study month if they received intensive psychotherapy (cognitive-behavioral therapy, family focused therapy, or IPSRT) than if they received collaborative care in addition to pharmacotherapy. They also had significantly higher year-end recovery rates and shorter times to recovery.
In a trial conducted by a separate research group, 100 participants aged 15–36 years with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified were randomized to IPSRT (n = 49) or specialist supportive care (n = 51). Both groups experienced improvement in depressive symptoms, social functioning, and manic symptoms, but there were no significant differences between the groups.
Adolescents
IPSRT was adapted to be delivered to adolescents with BD (IPSRT-A). In an open trial (N=12), feasibility and acceptability of IPSRT-A were high; 11/12 participants completed treatment, 97% of sessions were attended, and adolescent-rated satisfaction scores were high. IPSRT-A participants experienced significant decreases in manic, depressive, and general psychiatric symptoms over the 20 weeks of treatment. Participants’ global functioning increased significantly as well.
In an open trial aimed at prevention, adolescents (N=13) who were identified as high risk for bipolar disorder, due to having a first-degree relative with BD, received IPSRT. Significant changes in sleep/circadian patterns (i.e. less weekend sleeping in and oversleeping) were observed. Families reported high satisfaction with IPSRT, yet, on average, participants attended about half of scheduled sessions. Missed sessions were primarily associated with parental BD illness severity.
Group Therapy
IPSRT was adapted for a group therapy setting; administered over 16 sessions, in a semi-structured format. Patients (N=22) made interpersonal goals, reflected on how they managed their illness, and empathized with fellow group members. Patients were encouraged to react to each other from their own experience, express their feelings about what was said, and to give constructive feedback. Patients spent significantly less time depressed in the year following treatment than they did in the year prior to treatment.
In another small trial, patients with BD who experiencing a depressive episode (N = 9) received six IPSRT-G sessions across two weeks. Topics of discussion in group included defining interpersonal focus area, defining target times for daily routines, discussing grief and medication adherence, addressing interpersonal disputes and role transitions, and reviewing IPSRT strategies and relapse prevention. Depressive symptoms improved significantly at the end of the treatment; improvements were maintained 10 weeks following treatment end.
References
External links
The IPSRT (Interpersonal and Social Rhythm Therapy) website, supported by a NIMH grant
Bipolar disorder
Bipolar spectrum
Mood disorders
Psychotherapy by type
Treatment of bipolar disorder
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Functional analytic psychotherapy
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Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behavior analysis (CBA) that focuses on the therapeutic relationship as a means to maximize client change. Specifically, FAP suggests that in-session contingent responding to client target behaviors leads to significant therapeutic improvements.
FAP was first conceptualized in the 1980s by psychologists Robert Kohlenberg and Mavis Tsai who, after noticing a clinically significant association between client outcomes and the quality of the therapeutic relationship, set out to develop a theoretical and psychodynamic model of behavioral psychotherapy based on these concepts. Behavioral principles (e.g., reinforcement, generalization) form the basis of FAP. (See below.)
FAP is an idiographic (as opposed to nomothetic) approach to psychotherapy. This means that FAP therapists focus on the function of a client's behavior instead of the form. The aim is to change a broad class of behaviors that might look different on the surface but all serve the same function. It is idiographic in that the client and therapist work together to form a unique clinical formulation of the client's therapeutic goals, rather than one therapeutic target for every client who enters therapy.
Basics
FAP posits that client behaviors that occur in their out-of-session interpersonal relationships (i.e. in the "real world") will, if clients are given a therapeutic relationship of sufficiently high quality, occur in the therapy session as well. Based on these in-session behaviors, FAP therapists, in collaboration with their client, develop a case formulation that includes classes of behaviors (based on their function not their form) that the client wishes to increase and decrease.
In-session occurrence of a client's problematic behavior is called clinically relevant behavior 1 (CRB1). In-session occurrence of improvements is called clinically relevant behavior 2 (CRB2). The goal of FAP therapy is to decrease the frequency of CRB1s and increase the frequency of CRB2s.
The FAP therapist evokes (i.e. sets the context for) CRB1s and in response gradually shapes CRB2s.
The five rules
"The five rules" operationalize the FAP therapist's behavior with respect to this goal. It is important to note that the five rules are not rules in the traditional sense of the word, but instead a set of guidelines for the FAP therapist.
Rule 1: Watch for CRBs – Therapists focus their attention on the occurrence of CRBs that are in-session problems (CRB1s) and improvements (CRB2s).
Rule 2: Evoke CRBs – Therapists set a context which evoke the client's CRBs.
Rule 3: Reinforce CRB2s naturally – Therapists reinforce the occurrence of CRB2s (in-session improvements), increasing the probability that these behaviors will occur more frequently.
Rule 4: Observe therapist impact in relation to client CRBs – Therapists assess the degree to which they actually reinforced behavioral improvements by noting the client's behavior subsequent behavior after Rule 3. This is similar to the behavior analytic concept of performing a functional analysis.
Rule 5: Provide functional interpretations and generalize – Therapists work with the client to generalize in-session behavioral improvements to the client's out-of-session relationships. This can include, but is not limited to, providing homework assignments.
The ACL model
Researchers at the Center for the Science of Social Connection at the University of Washington are developing a model of social connection that they believe is relevant to FAP. This model – called the ACL model – delineates behaviors relevant to social connection based on decades of scientific research.
Awareness (A) behaviors include paying attention to your own and the other's needs and values within an interpersonal relationship.
Courage (C) behaviors include experiencing emotion in the presence of another person, asking for what you need, and sharing deep, vulnerable experiences with another person in the service of improving the relationship.
Love (L) behaviors involve responding to another's courage behaviors with attunement to what that person needs in the moment. These include providing safety and acceptance in response to a client's vulnerability.
FAP has the potential to target awareness, courage, and love behaviors as they occur in session as described by the five rules above. More research is needed to confirm the utility of the ACL model.
Research support
Radical behaviorism and the field of clinical behavior analysis have strong scientific support. Additionally, researchers have conducted a number of case studies, component process analyses, a study with non-randomized design on FAP-enhanced cognitive therapy for depression, and a randomized controlled trial on FAP-enhanced acceptance and commitment therapy for smoking cessation.
Third generation behavior therapy
FAP belongs to a group of therapies referred to as third-generation behavior therapies (or third-wave behavior therapies) that includes dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), behavioral activation (BA), and integrative behavioral couples therapy (IBCT).
Criticism
FAP has been criticized for "being ahead of the data", i.e. having not enough empirical support to justify its widespread use. Challenges encountered by FAP researchers are widely discussed
There is also criticism of using the ACL model as it detracts from the idiographic nature of FAP.
Professional organizations
Association for Contextual Behavioral Science (ACBS) – Founded in 2005 (incorporated in 2006), the Association for Contextual Behavioral Science (ACBS) is dedicated to the advancement of functional contextual cognitive and behavioral science and practice so as to alleviate human suffering and advance human well-being.
The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis. ABAI has larger special interest groups for behavioral medicine. ABAI serves as the core intellectual home for behavior analysts.
The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. In addition, the Association for Behavioral and Cognitive Therapies has a special interest group in addictions.
Doctoral level behavior analysts who are psychologists belong to the American Psychological Association's Division 25 (behavior analysis). APA offers a diplomate in behavioral psychology.
The World Association for Behavior Analysis offers a certification for clinical behavior analysis which covers functional analytic psychotherapy.
References
External links
Kohlenberg & Tsai's FAP website
Center for the Science of Social Connection
Cognitive behavioral therapy
Behaviorism
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Edwards Personal Preference Schedule
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Developed by psychologist and University of Washington professor Allen L. Edwards, the Edwards Personal Preference Schedule (EPPS) is a forced choice, objective, non-projective personality inventory. The target audience in between the ages of 16-85 and takes about 45 minutes to complete. Edwards derived the test content from the human needs system theory proposed by Henry Alexander Murray, which measures the rating of individuals in fifteen normal needs or motives. The EPPS was designed to illustrate relative importance to the individual of several significant needs and motives. It is useful in counseling situations when responses are reviewed with the examinee.
Murray's Theory of Psychogenic Needs
Murray's system of human needs has influenced the making of personality tests for years. By incorporating his theory into personality testing, one can determine how one may act in a specific situation, as an employee, student, parent... The list goes on and on... Following is an overview on Murray's theory.
American psychologist Henry Murray developed a theory of personality that was organized in terms of motives, presses, and needs. Murray described a need as a potentiality or readiness to respond in a certain way under certain given circumstances.
Theories of personality based upon needs and motives suggest that our personalities are a reflection of behaviors controlled by needs. While some needs are temporary and changing, other needs are more deeply seated in our nature. According to Murray, these psychogenic needs function mostly on the unconscious level, but play a major role in our personality.
The Personality Research Form and the Jackson Personality Inventory are also structured personality tests based on Murray's theory of needs but were constructed slightly differently than the EPPS in hopes of increasing validity.
Test Format
The 15 personality variable scales
On the EPPS there are nine statements used for each scale. Social Desirability ratings have been done for each item, and the pairing of items attempts to match items of approximately equal social desirability. Fifteen pairs of items are repeated twice for the consistency scale.
Achievement : A need to accomplish tasks well
Deference: A need to conform to customs and defer to others
Order: A need to plan well and be organized
Exhibition: A need to be the center of attention in a group
Autonomy: A need to be free of responsibilities and obligations
Affiliation: A need to form strong friendships and attachments
Intraception: A need to analyze behaviors and feelings of others
Succorance: A need to receive support and attention from others
Dominance: A need to be a leader and influence others
Degradation: A need to accept blame for problems and confess errors to others
Nurturance: A need to be of assistance to others
Change: A need to seek new experiences and avoid routine
Endurance: A need to follow through on tasks and complete assignments
Heterosexuality: A need to be associated with and attractive to members of the opposite sex
Aggression: A need to express one's opinion and be critical of others
(Edwards, 1959/1985)
Test Consistency
The inventory consists of 225 pairs of statements in which items from each of the 15 scales are paired with items from the other 14 plus the other fifteen pairs of items for the optional consistency check. This leaves the total number of items (14x15) at 210. Edwards has used the last 15 items to offer the candidate the same item twice, using the results to calculate a consistency score. The result will be considered valid if the consistency checks for more than 9 out of 15 paired items. Within each pair, the subjects choose one statement as more characteristic of themselves, reducing the social desirability factor of the test. Due to the forced choice, the EPPS is an ipsative test, the statements are made in relation to the strength of an individual's other needs. Hence, like personality, it is not absolute. Results of the test are reliable, although there are doubts about the consistency scale.
Validity
The manual reports studies comparing the EPPS with the Guilford Martin Personality Inventory and the Taylor Manifest Anxiety Scale.
Other researchers have correlated the California Psychological Inventory, the Adjective Check List, the Thematic Apperception Test, the Strong Vocational Interest Blank, and the MMPI with the EPPS. In these studies there are often statistically significant correlations among the scales of these tests and the EPPS, but the relationships are usually low-to-moderate and sometimes are difficult for the researcher to explain. Since the MMPI is still actively used today on a worldwide basis as a major brand test this comparison might be the most interesting to study.
Suggested Uses
The EPPS has been designed primarily for personal counselling, but has found its way into recruitment as well. The EPPS is very suitable for these purposes..
Reliability
The inter-correlations of the variables measured by EPPS are quite low. It indicates that the variables being measured are relatively independent and the schedule is quite reliable.
Copyrights
The EPPS has been published for a long period of time through The Psychological Corporation, now known as Harcourt Assessment. In 2002 the worldwide publishing rights have been returned by Harcourt to the Allen L. Edwards Living Trust. Internationally there is a translation in Dutch, which has been published in the Netherlands legally until 2002 (by Harcourt Test Publishers). There is also a translation into Japanese, published in 1970 by Nihon Bunka Kagakusha, Tokyo. The EPPS is translated into Spanish in 2014 in Mexico.
Currently copyrights are held by The Allen L Edwards Living Trust worldwide. The EPPS is published by Test Dimensions Publishers in English, Dutch and Spanish.
See also
Personality and Preference Inventory
References
Personality tests
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Diagnostic overshadowing
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Diagnostic overshadowing is the attribution of a person's symptoms to a psychiatric problem when such symptoms actually suggest a comorbid condition. Diagnostic overshadowing occurs when a healthcare professional assumes that a patient's complaint is due to their disability or coexisting mental health condition rather than fully exploring the cause of the patient's symptoms. Often, once a patient has a confirmed diagnosis, there is a tendency to attribute all new behaviors or symptoms to the original diagnosis. Diagnostic overshadowing increases the risk of further health complications and delay in accurate treatment. An example of diagnostic overshadowing may be a patient being diagnosed with a psychiatric problem and prescribed medication due to head banging behavior, but the patient actually has communication challenges and can't express pain in their mouth due to a dental abscess.
History
The term was first used to describe the underdiagnosis of mental illness in people with intellectual or developmental disabilities. In recent years, the term has also been used when physical illnesses are overlooked in people with mental illness.
Causes
Diagnostic overshadowing can occur for several reasons. Diagnostic shadowing most often occurs when a new behavior develops or previous abnormal behaviors increase. Staff inexperienced with working with people with intellectual disability are also more likely to mistakenly attribute symptoms of a physical illness to a person's intellectual disability. Time pressures of healthcare providers and stigma have been found to be additional causes of diagnostic overshadowing.
Impact
Diagnostic overshadowing can lead to inadequate medical treatment for physical health conditions in people with mental illnesses, leading to increased mortality and poorer treatment outcomes. The World Health Organization attributes lower life expectancy in people with intellectual disability or mental illnesses in part to diagnostic overshadowing. In addition to diagnostic overshadowing, people with intellectual disabilities experience barriers to accessing quality health care, increasing the likelihood of developing complex health conditions. People with intellectual disabilities are more likely to be impacted by diabetes, hypertension, obesity and on average die 16 years earlier than their peers without ID.
Diagnostic overshadowing can also lead to delays in treatment or support. When a developmental disorder- such as Autism- is not diagnosed due to diagnostic overshadowing, this can lead to a delay in appropriate support being provided.
Prevention
In the UK, the NHS recommends that local NHS trusts "have effective safeguarding arrangements" to prevent diagnostic overshadowing in people with intellectual disability and autism spectrum disorder. Healthcare providers play a significant role in helping to eliminate the risk of diagnostic overshadowing.
References
Medical diagnosis
Psychiatric assessment
Medical error
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Case study (psychology)
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Case study in psychology refers to the use of a descriptive research approach to obtain an in-depth analysis of a person, group, or phenomenon. A variety of techniques may be employed including personal interviews, direct-observation, psychometric tests, and archival records. In psychology case studies are most often used in clinical research to describe rare events and conditions, which contradict well established principles in the field of psychology. Case studies are generally a single-case design, but can also be a multiple-case design, where replication instead of sampling is the criterion for inclusion. Like other research methodologies within psychology, the case study must produce valid and reliable results in order to be useful for the development of future research. Distinct advantages and disadvantages are associated with the case study in psychology. The case study is sometimes mistaken for the case method, but the two are not the same.
Advantages
One major advantage of the case study in psychology is the potential for the development of novel hypotheses for later testing. Second, the case study can provide detailed descriptions of specific and rare cases
Disadvantages
Case studies cannot be used to determine causation.
Famous case studies in psychology
Harlow - Phineas Gage
Breuer & Freud (1895) - Anna O.
Cleckley's (1941) case studies of psychopathy (The Mask of Sanity) and multiple personality disorder (The Three Faces of Eve) (1957)
Freud and Little Hans
Freud and the Rat Man
John Money and the John/Joan case
Genie (feral child)
Piaget's studies
Rosenthal's book on the murder of Kitty Genovese
Washoe (sign language)
Patient H.M.
Lev Zasetsky (A.R. Luria)
Solomon Shereshevsky (A.R. Luria)
When Prophecy Fails published in 1956, this study was done on a group that believed aliens were going to save them soon as the world was about to end, and what would happen to them when the day of ending didn't happen.
See also
Case study
Research method
References
^ Schultz & Schultz, Duane (2010). Psychology and work today. New York: Prentice Hall. pp. 201–202. .
Psychological tests and scales
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Personality clash
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A personality clash occurs when two (or more) people find themselves in conflict not over a particular issue or incident, but due to a fundamental incompatibility in their personalities, their approaches to things, or their style of life.
A personality clash may occur in work-related, school-related, family-related, or social situations.
Types
Carl Jung saw the polarity of extraversion and introversion as a major potential cause of personality conflicts in everyday life, as well as underlying many past intellectual and philosophical disputes.
He also opposed thinking and feeling types, intuitive and sensation types, as potential sources of misunderstanding between people; while other typologies can and have been developed since.
In the workplace
The issue of personality clashes in the workplace is controversial. According to the Australian government, the two types of workplace conflicts are when people's ideas, decisions or actions relating directly to the job are in opposition, or when two people just don't get along. Turner and Weed argue that in a conflict situation, don’t ask who, ask what and why. Managers should avoid blaming interpersonal conflicts on personality clashes. Such a tactic is an excuse to avoid addressing the real causes of conflict, and the department’s performance will suffer as a result. Managers must be able to recognize the signs of conflict behaviors and deal with the conflict in a forthright fashion. Approaching conflicts as opportunities to improve departmental policies and operations rather as ailments to be eradicated or ignored will result in a more productive work force and greater departmental efficiency. However, in order to avoid recognizing harsher business bullying situations, employers are more likely to refer to these actions as a personality clash.
In therapy
Sigmund Freud thought a harmonious match of therapist and patient was essential for psychotherapy; but subsequent experience has demonstrated that success can follow even where there is an underlying personality clash.
Neville Symington indeed saw a patient's willingness to proceed with therapy, despite her dislike of him, as a positive sign of health, and as a beginning repudiation of her narcissism.
Remedies
Some suggest that the only answer to a personality clash is the folk remedy of distancing - reducing contact with the clashing personality involved. Other recommendations are to focus on the positives in the other person, and to examine one's own psychodynamics for clues as to why one is finding them so difficult - perhaps due to a projection of some unacknowledged part of one's own personality.
Howard Gardner saw a major part of what he called interpersonal intelligence as the ability to mediate and resolve such personality clashes from the outside.
Examples
Actual
Circumstances conspired to produce a painful personality clash between the ordered, cerebral, emotionally contained A. J. P. Taylor, and the spendthrift, bohemian, expansive Dylan Thomas.
The clash between the cautious, moderate Harley and the mercurial, extremist Bolingbroke at the close of Queen Anne's reign did much to usher in the long Whig ascendency that followed.
The personality clash between Henry Tizard and Frederick Lindemann had adverse effects on the Allied conduct of World War Two.
Literary
C. P. Snow in his semi-autobiographical novel on the corridors of power described caballing with someone whose temperament "clashed right at the roots with mine: even if he was not being offensive, he would have tempted me to say something hard. But I was doing a job, and I couldn't afford luxuries, certainly not the luxury of being myself".
See also
References
Further reading
C. G. Jung, Psychological Types (London 1971)
Ronald W. Clark, Tizard (London 1965)
External links
Philip Landau, 'When personalities clash'
'Workplace conflict'
Personality
Organizational conflict
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Quality of life (healthcare)
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In general, quality of life (QoL or QOL) is the perceived quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. This includes all emotional, social and physical aspects of the individual's life. In health care, health-related quality of life (HRQoL) is an assessment of how the individual's well-being may be affected over time by a disease, disability or disorder.
Measurement
Early versions of healthcare-related quality of life measures referred to simple assessments of physical abilities by an external rater (for example, the patient is able to get up, eat and drink, and take care of personal hygiene without any help from others) or even to a single measurement (for example, the angle to which a limb could be flexed).
The current concept of health-related quality of life acknowledges that subjects put their actual situation in relation to their personal expectation. The latter can vary over time, and react to external influences such as length and severity of illness, family support, etc. As with any situation involving multiple perspectives, patients' and physicians' rating of the same objective situation have been found to differ significantly. Consequently, health-related quality of life is now usually assessed using patient questionnaires. These are often multidimensional and cover physical, social, emotional, cognitive, work- or role-related, and possibly spiritual aspects as well as a wide variety of disease related symptoms, therapy induced side effects, and even the financial impact of medical conditions. Although often used interchangeably with the measurement of health status, both health-related quality of life and health status measure different concepts.
Activities of daily living
Activities of Daily Living (ADLs) are activities that are oriented toward taking care of one's own body and are completed daily. These include bathing/showering, toileting and toilet hygiene, dressing, eating, functional mobility, personal hygiene and grooming, and sexual activity. Many studies demonstrate the connection between ADLs and health-related quality of life (HRQOL). Mostly, findings show that difficulties in performing ADLs are directly or indirectly associated with decreased HRQOL. Furthermore, some studies found a graded relationship between ADL difficulties/disabilities and HRQOL- the less independent people are at ADLs- the lower their HRQOL is. While ADLs are an excellent tool to objectively measure quality of life, it is important to remember that Quality of life goes beyond these activities. For more information about the complex concept of quality of life, see information regarding the disability paradox.
In addition to ADLs, instrumental activities of daily living (IADLs) can be used as a relatively objective measure of health-related quality of life. IADLs, as defined by the American Occupational Therapy Association (AOTA), are “Activities to support daily life within the home and community that often require more complex interactions than those used in ADLs”. IADLs include tasks such as: care for others, communication management, community mobility, financial management, health management, and home management. Activities of IADLS includes: grocery shopping, preparing food, housekeeping, using the phone, laundry, managing transportation/finances. Research has found that an individual's ability to engage in IADLs can directly impact their quality of life.
Pharmacology for older adults
Elderly patients taking more than five medications increases risk of cognitive impairment, and is one consideration when assessing what factors impact QoL, ADLs, and IADLs of older adults. Due to multiple chronic conditions, managing medications in this group of people is particular challenging and complex. Recent studies showed that polypharmacy is associated with ADL disability due to malnutrition, and is a risk factor for hospital admission due to falls, which can have severe consequences on a person's quality of life moving forward. Thus, when assessing an elderly person's quality of life, it is important to consider the medications an older patient is taking, and whether they are adhering to their current prescription taking schedule.
Occupational Therapy's Role
Occupational therapists (OTs) are global healthcare professionals who treat individuals to achieve their highest level of quality of life and independence through participation in everyday activities. OTs are trained to complete a person-centered evaluation of an individual's interests and needs, and tailor their treatment to specifically address ADLs and IADLs that their patient values. In the AOTAs most recent vision statement (2025) they explicitly state that OT as an inclusive profession works to maximize quality of life through the effective solution of participation in everyday living. To learn more about occupational therapy, see the Wikipedia page dedicated to the profession.
Special Considerations in Palliative Care
HRQoL in patients with serious, progressive, life-threatening illness should be given special considerations in both the measurement and analysis of HRQoL. Oftentimes, as level of functioning deteriorates, more emphasis is put on caregiver and proxy questionnaires or abbreviated questionnaires. Additionally, as diseases progress, patients and families often shift their priorities throughout the disease course. This can affect the measurement of HRQoL as, oftentimes, patients change the way they respond to questionnaires which results in HRQoL staying the same of even improving as their physical condition worsens. To address this issue, researchers have developed new instruments for measuring end-of-life HRQoL that incorporate factors such as sense of completion, relations with the healthcare system, preparation, symptom severity, and affective social support. Additionally, research is being conducted on the impact of existential QoL on palliative care patients as terminal illness awareness and symptom burden may be associated with lower existential QoL.
Examples
Similar to other psychometric assessment tools, health-related quality of life questionnaires should meet certain quality criteria, most importantly with regard to their reliability and validity. Hundreds of validated health-related quality of life questionnaires have been developed, some of which are specific to various illnesses. The questionnaires can be generalized into two categories:
Generic instruments
CDC HRQOL–14 "Healthy Days Measure": A questionnaire with four base questions and ten optional questions used by the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/hrqol/hrqol14_measure.htm).
Short-Form Health Survey (SF-36, SF-12, SF-8): One example of a widely used questionnaire assessing physical and mental health-related quality of life. Used in clinical trials and population health assessments. Suitable for pharmacoeconomic analysis, benefiting healthcare rationing.
EQ-5D a simple quality of life questionnaire (https://euroqol.org).
AQoL-8D a comprehensive questionnaire that assesses HR-QoL over 8 domains - independent living, happiness, mental health, coping, relationships, self-worth, pain, senses (https://www.aqol.com.au).
Disease, disorder or condition specific instruments
King's Health Questionnaire (KHQ)
International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) in urinary incontinence, the LC -13 Lung Cancer module from the EORTC Quality of Life questionnaire library, or the Hospital Anxiety and Depression Scale (HADS) ).
Manchester Short Assessment of Quality of Life: 16-item questionnaire for use in psychiatric populations.
ECOG, most commonly used to evaluate the impact of cancer on people.
NYHA scale, most commonly used to evaluate the impact of heart disease on individuals.
EORTC measurement system for use in clinical trials in oncology. These tools are robustly tested and validated and translated. A large amount of reference data is now available. The field of HRQOL has grown significantly in the last decade, with hundreds of new studies and better reporting of clinical trials. HRQOL appears to be prognostic for survival in some diseases and patients.
WHO-Quality of life-BREF (WHOQOL-BREF): A general Quality of life survey validated for several countries.
The Stroke Specific Quality Of Life scale SS-QOL: It is a patient-centered outcome measure intended to provide an assessment of health-related quality of life (HRQOL) specific to patients with stroke only. It measures energy, family roles, language, mobility, mood, personality, self care, social roles, thinking, upper extremity function, vision and work productivity.
In rheumatology, condition specific instruments have been developed such as RAQoL for rheumatoid arthritis, OAQoL for osteoarthritis, ASQoL for ankylosing spondylitis, SScQoL for systemic sclerosis and PsAQoL for people with psoriatic arthritis.
MOS-HIV(Medical Outcome Survey-HIV) was developed specifically for people living with HIV/AIDS.
Utility
A variety of validated surveys exist for healthcare providers to use for measuring a patient's health-related quality of life. The results are then used to help determine treatment options for the patient based on past results from other patients, and to measure intra-individual improvements in QoL pre- and post-treatment.
When it is used as a longitudinal study device that surveys patients before, during, and after treatment, it can help health care providers determine which treatment plan is the best option, thereby improving healthcare through an evolutionary process.
Importance
There is a growing field of research concerned with developing, evaluating, and applying quality of life measures within health related research (e.g. within randomized controlled studies), especially in relation to Health Services Research. Well-executed health-related quality of life research informs those tasked with health rationing or anyone involved in the decision-making process of agencies such as the Food and Drug Administration, European Medicines Agency or National Institute for Clinical Excellence. Additionally, health-related quality of life research may be used as the final step in clinical trials of experimental therapies.
The understanding of Quality of Life is recognized as an increasingly important healthcare topic because the relationship between cost and value raises complex problems, often with high emotional attachment because of the potential impact on human life. For instance, healthcare providers must refer to cost-benefit analysis to make economic decisions about access to expensive drugs that may prolong life by a short amount of time and/or provide a minimal increase to quality of life. Additionally, these treatment drugs must be weighed against the cost of alternative treatments or preventative medicine. In the case of chronic and/or terminal illness where no effective cure is available, an emphasis is placed on improving health-related quality of life through interventions such as symptom management, adaptive technology, and palliative care. Another example of why understanding quality of life is important is during a randomized study of 151 patients with metastatic non-small-cell lung cancer who were split into obtaining early palliative and standardized care group. The earlier palliative group not only had better quality of life based on the Functional assessment of Cancer Therapy-Lung scale and the Hospital Anxiety and Depression Scale, but the palliative care group also had less depressive symptoms (16% vs. 38%, P=0.01) despite having received less aggressive end-of-life care (33% vs. 54%, P=0.05) and longer median overall survival than the standard group (11.6 months vs. 8.9 months, P=0.02). By having a quality of life measure, we are able to evaluate early palliative care and see its value in terms of improving quality of care, reduced aggressive treatment and consequently costs, and also greater quality/quantity of life.
In the realm of elder care, research indicates that improvements in quality of life ratings may also improve resident outcomes, which can lead to substantial cost savings over time. Research has shown that evaluating an elderly person's functional status, in addition to other aspects of their health, helps improve geriatric quality of life and decrease caregiver burden. Research has also shown that quality of life ratings can be successfully used as a key-performance metric when designing and implementing organizational change initiatives in nursing homes.
Research
Research revolving around Health Related Quality of Life is extremely important because of the implications that it can have on current and future treatments and health protocols. Thereby, validated health-related quality of life questionnaires can become an integral part of clinical trials in determining the trial drugs' value in a cost-benefit analysis. For example, the Centers for Disease Control and Prevention (CDC) is using their health-related quality of life survey, Healthy Day Measure, as part of research to identify health disparities, track population trends, and build broad coalitions around a measure of population health. This information can then be used by multiple levels of government or other officials to "increase quality and years of life" and to "eliminate health disparities" for equal opportunity.
Within the field of childhood cancer, quality of life is often measured both during and after treatment. International comparisons of both outcomes and predictors are hindered by the use of a large number of different measurements. Recently, a first step for a joint international consensus statement for measuring quality of survival for patients with childhood cancer has been established.
Ethics
The quality of life ethic refers to an ethical principle that uses assessments of the quality of life that a person could potentially experience as a foundation for making decisions about the continuation or termination of life. It is often used in contrast to or in opposition to the sanctity of life ethic.
While measuring tools can be a way to scientifically quantify quality of life in an objective manner on a broad range of topics and circumstances, there are limitations and potential negative consequences with its utilization. Firstly, it makes the assumption that an assessment can be able to quantify domains such as physical, emotional, social, well-being, etc. with a single quantitative score. Furthermore, how are these domains weighted? Will they be measured the same or equally for each person? Or will it take into account how important these specific domains are for each person when creating the final score? Each person has their own specific set of experiences and values and a point of argument is that this needs to be taken into account. However, this would be a difficult task for the person to rank these quality of life domains. Another point to keep in mind is that people's values and experiences change over time and their quality of life domain rankings may differ. This caveat must be added or the dynamics of this could be taken into account when interpreting and understanding the results from a quality of life measuring tool. Quality of life measuring tools can also promote a negative and pessimistic view for clinicians, patients, and families, especially when used at baseline during the time of diagnosis. Quality of life measuring tools can fail to account for effective therapeutic strategies that can alleviate health burdens, and thus can promote a self-fulfilling prophecy for patients. On a societal level, the concept of low quality of life can also perpetuate negative prejudices experienced by people with disabilities or chronic illnesses.
Analysis
Statistical biases
It is not considered uncommon for there to be some statistical anomalies during data analysis. Some of the more frequently seen in health-related quality of life analysis are the ceiling effect, the floor effect, and response shift bias.
The ceiling effect refers to how patients who start with a higher quality of life than the average patient do not have much room for improvement when treated. The opposite of this is the floor effect, where patients with a lower quality of life average have much more room for improvement. Consequentially, if the spectrum of quality of life before treatment is too unbalanced, there is a greater potential for skewing the end results, creating the possibility for incorrectly portraying a treatment's effectiveness or lack thereof.
Response shift bias
Response shift bias is an increasing problem within longitudinal studies that rely on patient reported outcomes. It refers to the potential of a subject's views, values, or expectations changing over the course of a study, thereby adding another factor of change on the end results. Clinicians and healthcare providers must recalibrate surveys over the course of a study to account for Response Shift Bias. The degree of recalibration varies due to factors based on the individual area of investigation and length of study.
Statistical variation
In a study by Norman et al. about health-related quality of life surveys, it was found that most survey results were within a half standard deviation. Norman et al. theorized that this is due to the limited human discrimination ability as identified by George A. Miller in 1956. Utilizing the Magic Number of 7 ± 2, Miller theorized that when the scale on a survey extends beyond 7 ± 2, humans fail to be consistent and lose ability to differentiate individual steps on the scale because of channel capacity.
Norman et al. proposed health-related quality of life surveys use a half standard deviation as the statistically significant benefit of a treatment instead of calculating survey-specific "minimally important differences", which are the supposed real-life improvements reported by the subjects. In other words, Norman et al. proposed all health-related quality of life survey scales be set to a half standard deviation instead of calculating a scale for each survey validation study where the steps are referred to as "minimally important differences".
See also
Medical law
Patient-reported outcome
Pharmacoeconomics
Medical ethics
References
External links
ProQolid (Patient-Reported Outcome & Quality of Life Instruments Database)
Mapi Research Trust ("Non-profit organization involved in Patient-Centered Outcomes")
PROLabels(Database on Patient-Reported Outcome claims in marketing authorizations)
Quality-of-Life-Recorder (Project to bring QoL measurement to routine practice. Platform & library of electronic questionnaires, Shareware/Freeware)
The International Society for Quality of Life
Health and Quality of Life Outcomes
The Healthcare Center. Better Health for Everyone
Health care
Medical terminology
Healthcare
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Tranquillity
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Tranquillity (also spelled tranquility) is the quality or state of being tranquil; that is, calm, serene, and worry-free. The word tranquillity appears in numerous texts ranging from the religious writings of Buddhism—where the term refers to tranquillity of the body, thoughts, and consciousness on the path to enlightenment—to an assortment of policy and planning guidance documents, where interpretation of the word is typically linked to engagement with the natural environment. It is also famously used in the Preamble to the United States Constitution, which describes one of the purposes for which the document was establishing the government as to "insure domestic Tranquility".
History
The word tranquility dates to the 12th century in the Old French word , meaning "peace" or "happiness". The word's sense evolved in the late 14th century, but it maintains its reference to the absence of disturbance and peacefulness.
Benefits
Being in a tranquil or "restorative" environment allows people to take respite from the periods of sustained "directed attention" that characterise modern living. In developing their Attention Restoration Theory (ART), Kaplan and Kaplan proposed that people could most effectively recover from cognitive overload by engaging with natural restorative environments, those that are away from daily distractions and that have the extent and mystery that allows the imagination to wander, thereby enabling people to engage effortlessly with their surroundings. According to the theory, the amount of reflection possible within such an environment depends upon the type of cognitive engagement (fascination) that the environment . "Soft fascination" is deemed to occur when there is enough interest in the surroundings to hold attention but not so much that it compromises the ability to reflect. It provides a pleasing level of sensory input that involves no cognitive effort other than removing oneself from an overcrowded mental space.
Enjoyment
For many, the chance to experience tranquillity is an advantage of the countryside over cities. In a survey by the United Kingdom Department for Environment, Food and Rural Affairs (DEFRA) 58% of people said that tranquillity was the most positive feature of the countryside.
Health
In contrast to "soft fascination", "directed attention" requires a significant amount of cognitive effort. Prolonged periods of sustained mental activity can lead to directed attention fatigue. This can affect performance and bring about negative emotions, irritability, and decreased sensitivity to interpersonal cues. As the incidence of mental illness continues to rise, there is growing evidence that exposure to natural environments can contribute to health and wellbeing. Exposure to nature contributes to physical and psychological wellbeing. One found evidence of "nature-deficit-disorder" in children, which suggests that the importance of being able to engage with restorative environments applies across a wide age range.
Natural tranquil surroundings affect the psychology of people suffering from stress. For example, one study found that stress (as measured by blood pressure, muscle tension, and skin conductance response), induced by showing videos of workplace injuries, improved significantly more quickly if further videos viewed included natural surroundings rather than busy traffic or shopping scenes. Another study demonstrated the benefits of simulating such environments for pain relief during bone marrow aspirate and biopsy.
Economic
The presence of tranquil areas helps boost rural tourism. Rural tourism in the U.K. supports 380,000 jobs and contributes annually to the rural economy, and one survey showed that tranquillity is the main reason why 49% of visitors are attracted to the countryside.
Research
Natural settings that effortlessly engage our attention are associated with soft fascination and with the analysis of tranquillity discussed above. One study attempted to distinguish empirically between the constructs of tranquillity and preference as affective qualities of natural environments. Motivated by ART, from which they took tranquillity as a reasonable term to describe soft fascination, they produced definitions for each component. Tranquillity they defined as "how much you think this setting is a quiet, peaceful place, a good place to get away from everyday life", and preference as "how much you like this setting for whatever reason". Subjects were asked to score the following visual settings: mountains, deserts, fields / forests, and waterscapes against those two target variables (tranquillity and preference) and four descriptor variables: mistiness, unstructured openness, focus, and surface calmness. Tranquillity and preference were positively correlated across all settings with tranquillity scoring higher ratings in the field / forest, waterscape, and mountain categories, whilst rushing water had the highest rating in the preference category.
Analysis of the results identified three physical features that help explain the apparent split between tranquillity and preference: mistiness, unstructured openness (how open the scene is and how difficult it is to establish a sense of depth or distance), and surface calmness. Mistiness and unstructured openness tended to depress preference relative to tranquillity whilst surface calmness tended to enhance it. A follow-up study included deserts and waterscapes in the setting types.
Another study investigated the relationship between tranquillity and danger in urban and rural settings. The key results were 1) that "setting care", which relates to how safe we feel in a particular setting, is more salient for judgments of danger in urban settings than natural ones, and 2) that openness was a significant predictor of danger but not of tranquillity. The authors concluded that tranquillity and danger should not be viewed as polar opposites, but, like preference and tranquillity, as distinct constructs.
The role of audio-visual interaction within the tranquillity construct
Within tranquillity studies, much of the emphasis has been placed on understanding the role of vision in the perception of natural environments. People can very quickly form an impression of a landscape upon viewing it. The speed with which people process complex natural images was tested by using colour photographs of a wide range of animals (mammals, birds, reptiles, and fish) in their natural environments, mixed with distracters that included pictures of forests, mountains, lakes, buildings, and fruit. During this experiment, subjects were shown an image for 20ms and asked to determine whether it contained an animal or not. The electrophysiological brain responses obtained in this study showed that a decision could be made within 150ms of the image being seen, indicating the speed at which cognitive visual processing occurs.
Audition, and the components that comprise the soundscape (a term coined by Schafer to describe the array of sounds that constitute the sonic environment) also inform the ways people characterise landscapes. Auditory reaction times are 50 to 60ms faster than visual ones. Sound can also alter visual perception, and under certain conditions areas of the brain involved in processing auditory information can be activated in response to visual stimuli.
When individuals make tranquillity assessments based on a uni-modal auditory or visual sensory input, they characterise the environment by drawing upon a number of key landscape and soundscape characteristics. For example, when making assessments in response to visual-only stimuli the percentage of water, flora, and geological features positively influence how tranquil a location is perceived to be. Likewise when responding to uni-modal auditory stimuli, the perceived loudness of biological sounds positively influences the perception of tranquillity, whilst the perceived loudness of mechanical sounds have a negative effect. However, when presented with bi-modal auditory-visual stimuli the individual soundscape and landscape components alone no longer influence the perception of tranquillity. Rather configurational coherence was provided by the percentage of natural and contextual features present within the scene and the equivalent continuous sound pressure level (LAeq).
Predicting tranquillity
Researchers at the Bradford Centre for Sustainable Environments developed a methodology with which the perceived tranquillity rating (TR) of an amenity area such as park, green, or urban square can be measured, on a 0–10 scale. The method involves assessing average daytime noise levels Lday (usually traffic noise) and measuring the percentage of natural and contextual features (NCF) contained within the visual scene. The latter includes the percentage area in the visual scene occupied by natural features in the landscape such as vegetation, water, and geological features (for example, exposure of rock), and contextual features such as listed buildings, religious and historic buildings, landmarks, monuments, and elements of the landscape such as traditional farm buildings that directly contribute to the visual context of the natural environment. Lastly, moderating factors (MF) also occur that can influence the perception of tranquillity. The moderating factors are not large; because they are relatively difficult to quantify they are the subject of ongoing research. The TR of an area is then a function of noise, NCF, and MF.
One potentially effective solution to improving tranquillity is to mask traffic noise or distract attention from it with an attractive water sound. Water-generated sounds may improve the perceived tranquillity of gardens blighted by noise. Litter can degrade an environment such that the tranquillity rating drops on average by one .
A study using fMRI neuro-imaging techniques demonstrated the significant differences in effective connectivity between areas of the brain, namely the auditory cortex and the medial pre-frontal cortex, under tranquil and non-tranquil conditions. Specifically the medial pre-frontal cortex receives significantly enhanced contributions from the auditory cortex when presented with a more tranquil visual scene.
Mapping tranquillity
The first method of mapping tranquillity was developed by Simon Rendel of ASH Consulting for a Department for Transport study in 1991. This led to the production of a set of Tranquil Area maps covering England, produced by Rendel and ASH Consulting and published by the Campaign to Protect Rural England (CPRE) and the former Countryside Commission.
In these maps tranquil areas were defined as "places sufficiently far from the visual or noise intrusion of development or traffic to be considered unspoilt by urban influences".
More sophisticated mapping techniques are now available following work by researchers at Northumbria University, Newcastle University, and CPRE.
Maps have been produced for the whole of England that show the tranquillity score of Ordnance Survey Grid-derived 500m×500m squares. The tranquillity rating for each is based on 44 factors that add to or detract from people’s feelings of tranquillity. These factors were defined following extensive public consultations.
The methodology examines the diffusion of the impact of these factors over distance, taking into account the terrain of the land. For example, the tranquillity increases gradually the further one is from a busy road, but increases more sharply if the road is hidden in a cutting.
This cartographic study showed that tranquillity is not the absence of all noise, activity, and buildings. Indeed, it found that many rural activities, such as farming and hiking, and natural noises such as birdsong and cows lowing, enhance people’s experience of tranquillity.
Some factors with positive impacts on tranquillity
a natural landscape, including woodland
presence of rivers, streams, lakes or the sea
birds and other wildlife
wide open spaces
clear open night sky with/without moon
beach in a unique location
open field, flora etc. with gentle to moderate wind flow
Some factors with negative impacts on tranquillity
Motorised transport: cars, motorcycle, trains and aircraft – and roads and railways
light pollution
large numbers of people
pylons, power lines, masts and wind turbines
noise
See also
Inner peace
References
Environmental psychology
Virtue
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Ritvo Autism and Asperger Diagnostic Scale
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The Ritvo Autism & Asperger Diagnostic Scale (RAADS) is a psychological self-rating scale developed by Dr. Riva Ariella Ritvo (NPI UCLA and CSC Yale). An abridged and translated 14 question version was then developed at the Department of Clinical Neuroscience at the Karolinska Institute, to aid in the identification of patients who may have undiagnosed ASD.
Background
Autism is often difficult to diagnose in adults due to overlapping symptoms with various other disorders. This can lead to a misdiagnosis, or an entirely missed diagnosis of ASD. This poses a challenge to psychiatrists in identifying undiagnosed adults who may have autism. Adults are being referred or self referred for diagnosis with increasing frequency, making this a useful clinical tool. A score of 64 or more has been shown to be consistent and support a clinical diagnosis, but in the case the clinical diagnosis differs from the test score, the clinical diagnosis should take precedence. Many studies suggest that adults can remain undiagnosed due to the difficulty of gaining an accurate history of the adult's development through childhood, milder presenting or less common traits, and lack of accurate knowledge from medical professionals.
The test itself has been revised and has multiple iterations: RAADS, RAADS-R, and RAADS-14. The RAADS-14 differs most dramatically, consisting of 14 questions organised into three domains: mentalizing deficits, sensory reactivity, and social anxiety. The RAADS-R, revised in 2011 after the original in 2008, has 80 questions organised into four domains: social relatedness, circumscribed interests, language, and sensory-motor symptoms. The test itself is formatted with an answering mechanism akin to a likert scale, with participants providing a response to statements with answers of varying severity, such as whether a behaviour was experienced now and when young, only true now, only when young, or never true.
Uses
The test itself is free to access, and is often used as a means of self-assessment, taking approximately 10–30 minutes to complete. Ritvo, the creator of the assessment, states that the test as a whole is best utilised as a clinical tool completed with a clinician present. This also allows for direct communication between patient and clinician, which Ritvo states is a valuable addition for diagnostic purposes.
The RAADS-R test is available online in English and Swedish and has been translated into various languages for the purpose of assessing its accuracy in identifying ASD, in addition to its performance in comparison to other popular diagnostic tools. When translated for participants in the Netherlands, the RAADS-R correctly identified ASD in 80% of cases, with high sensitivity as opposed to another popular measure, the AQ. The French version of the RAADS-R demonstrates a high standard of validity and reliability in identifying adults who have ASD.
Diagnostic accuracy
One advantage that the RAADS-R has in comparison to other commonly used autism screening tests is that it has specific questions that target hyposensitivity and hypersensitivity, which correlates with diagnostic criteria in the DSM-5. The RAADS-R is also recommended by the National Institute for Health and Care Excellence, or NICE, which operates within the UK in order to provide nationwide healthcare guidelines. Research conducted in English countries looked at the effectiveness of the RAADS-R test, and found that it was an effective tool in order to expedite a diagnosis with adult mental health services, but should not be used in isolation. Further research published in Autism in the United States found that the test is generally accurate. The participants' age, gender, autism diagnosis, or self diagnosis did not impact how they answered the questions presented.
Comorbidities
Further uses of the RAADS-R test can be seen with its application to identifying comorbidities, or the existence of multiple disorders with overlapping symptoms that can be identified as symptoms of ASD. The RAADS-R test has been used to assess symptoms of autism present in those with eating disorders, as some studies suggest a possible correlation between eating disorders and ASD. This is due to the overlap and similarities between the two providing common struggles, such as those pertaining to social skills and communication. An Italian version of the test was created to assess a possible correlation and comorbidity between eating disorders and ASD, and found that 33% of patients with eating disorders presented with high ASD traits, with the RAADS-R showing high agreement.
ASD has also been shown to play a role in those with diagnosed bipolar disorder among multiple other comorbidities. This case study revealed another use for the RAADS-R in identifying possible comorbidities, and the repeated likelihood of missed diagnosis in adulthood that can be unearthed using the test, despite frequent symptom overlap.
The RAADS-14, the 14 question version of the test, has been applied to use in New Zealand. Generally it has been proven to be a valid measure, correlating strongly with the Autism Spectrum Quotient, or AQ-10. However, when applied to a New Zealand population, the test has high sensitivity, but not specificity, resulting in a higher number of false positives when solely relying upon test scores. The authors of the above research state a possible improvement to the RAADS-14 through modification of its psychometric properties to suit a particular cultural group.
Limitations
There are a few limitations to the RAADS test that make it important to use alongside professional clinical diagnostic processes. Some limitations may include questions being misinterpreted or misunderstood, unawareness or over-reporting of symptoms, and the same symptoms being rated different levels of "obtrusiveness" in daily functioning.
The RAADS test has only shown moderate accuracy in clinical settings. It has also been shown to require further academic study due to its likelihood of returning a false positive. In an evaluation of the screening effectiveness of the RAADS-R among 50 participants, there was no association between RAADS-R scores and a future clinical diagnosis of autism.
See also
Diagnostic classification and rating scales used in psychiatry
Autism
Asperger syndrome
References
External links
Online version of the RAADS-14 (14-item version)
Autism screening and assessment tools
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Metapsychology
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Metapsychology (Greek: meta 'beyond, transcending', and ψυχολογία 'psychology') is that aspect of a psychological theory that discusses the terms that are essential to it, but leaves aside or transcends the phenomena that the theory deals with. Psychology refers to the concrete conditions of the human psyche, metapsychology to psychology itself. (Cf. also the comparison of metaphysics and physics)
The term is used mostly in discourse about psychoanalysis, the psychology developed by Sigmund Freud. In general, his metapsychology represents a technical elaboration of his structural model of the psyche, which divides the organism into three instances: the id is considered the germ from which the ego and the superego emerge. Driven by an energy that Freud called libido in direct reference to Plato's Eros, the instances complement each other through their specific functions in a similar way to the parts of a microscope or organelles of a cell. More precisely defined, metapsychology describes ‘a way of obversation in which every psychic process is analysed according to the three coordinates of dynamics, topics and economy’. Topology refers to the arrangement of these processes in space, dynamics to their movements (variability, also in time) and economy to the energetic reservoir (libido) that drives all life processes, is used up during this and therefore needs to be replenished through nutrition.
These precise concepts led Freud to say that their unified presentation would make it possible to achieve the highest goal of psychology, namely the development of a comprehensively founded model of health. Such an idea is crucial for the diagnostic process because illnesses - the treatment and prevention of which is the focus of all medical activity - can only be recognised in contrast to or as deviations from a state of health.
Freud left this central part of his work to future analysts in the unfinished state of a Torso, since - as he stated - the fields of knowledge required to complete metapsychology were barely developed or did not exist in the first half of the 20th century. This refers above all to ethological primate research and its extension to the field of anthropology. Freud considers findings from these areas of knowledge to be indispensable because without them it is not possible to examine and, where necessary, correct his hypothesis of natural social coexistence in the primordial horde postulated by Darwin (see presented for discussion in Totem and Taboo). The same applies to the hypothetical abolition of horde life through the introduction of monogamy by a corresponding agreement among the sons who killed the primal father of the horde. For the same reasons, Freud's claim also extends to the assumed origin of moral codes of behavior (totemism), the differentiation of sexual from social and intellectual needs (instinctively formed communities versus consciously conceived political superstructures; foundations of belief and knowledge systems), and much more. In Moses and Monotheism, the author refers one last time to the lack of primate research at the time.
The empirical foundations of Freudian metapsychology are neurological processes and close relationships to Darwin's theory of evolution. The libidinal energy, which according to this metapsychology drives all biological and mental processes through its inherent desire, represents in a certain sense a teleological thesis.
More recently it's regarded as a hermeneutics of understanding with relations to Freud's literary sources, especially Sophocles and, to a lesser extent, Goethe and Shakespeare. Interest on the possible scientific status of psychoanalysis has been renewed in the emerging discipline of neuropsychoanalysis, whose major exemplar is Mark Solms. The hermeneutic vision of psychoanalysis is the focus of influential works by Donna Orange.
Freud and the als ob problem
Psychoanalytic metapsychology is concerned with the fundamental structure and concepts of Freudian theory. Sigmund Freud first used the term on 13 February 1896 in a letter to Wilhelm Fliess, to refer to his addition of unconscious processes to the conscious ones of traditional psychology. On March 10, 1898, he wrote to Fliess: "It seems to me that the theory of wish fulfillment has brought only the psychological solution and not the biological - or, rather, metapsychical - one. (I am going to ask you seriously, by the way, whether I may use the name metapsychology for my psychology that leads behind consciousness)." Three years after completing his unpublished Project for a Scientific Psychology, Freud's optimism had completely vanished. In a letter dated September 22 of that year he told Fliess: "I am not at all in disagreement with you, not at all inclined to leave psychology hanging in the air without an organic basis. But apart from this conviction, I do not know how to go on, neither theoretically nor therapeutically, and therefore must behave as if [als läge] only the psychological were under consideration. Why I cannot fit it together [the organic and the psychological] I have not even begun to fathom". "When, in his 'Autobiographical Study' of 1925, Freud called his metapsychology a 'speculative superstructure'...the elements of which could be abandoned or changed once proven inadequate, he was, in the terminology of Kant's Critique of Judgment, proposing a psychology als ob or as if – a heuristic model of mental functioning that did not necessarily correspond with external reality."
A salient example of Freud's own metapsychology is his characterization of psychoanalysis as a "simultaneously closed system, fundamentally unrelated and impervious to the external world and as an open system inherently connected and responsive to environmental influence.
In the 1910s, Freud wrote a series of twelve essays, to be collected as Preliminaries to a Metapsychology. Five of these were published independently under the titles: "Instincts and Their Vicissitudes," "Repression," "The Unconscious," "A Metapsychological Supplement to the Theory of Dreams," and "Mourning and Melancholia." The remaining seven remained unpublished, an expression of Freud's ambivalence about his own attempts to articulate the whole of his vision of psychoanalysis. In 1919 he wrote to Lou Andreas-Salome, "Where is my Metapsychology? In the first place it remains unwritten". In 1920 he published Beyond the Pleasure Principle, a text with metaphysical ambitions.
Midcentury psychoanalyst David Rapaport defined the term thus: "Books on psychoanalysis usually deal with its clinical theory... there exists, however, a fragmentary—yet consistent—general theory of psychoanalysis, which comprises the premises of the special (clinical) theory, the concepts built on it, and the generalizations derived from it... named metapsychology."
Freud's metapsychology
The topographical point of view: the psyche operates at different levels of consciousness - unconscious, preconscious, and conscious
The dynamic point of view: the notion that there are psychological forces which may conflict with one another at work in the psyche
The economic point of view: the psyche contains charges of energy which are transferred from one element of the psyche to another
The structural point of view: the psyche consists of configurations of psychological processes which operate in different ways and reveal different rates of change - the ego, the id, and the superego
The genetic point of view: the origins - or "genesis" - of psychological processes can be found in developmentally previous psychological processes
Ego psychologist Heinz Hartmann also added 'the adaptive" point of view' to Freud's metapsychology, although Lacan who interpreted metapsychology as the symbolic, the Real, and the imaginary, said "the dimension discovered by analysis is the opposite of anything which progresses through adaptation."
Criticism
Freud's metapsychology has faced criticism, mainly from ego psychology. Object relations theorists such as Melanie Klein, shifted the focus away from intrapsychic conflicts and towards the dynamics of interpersonal relationships, leading to a unifocal theory of development that focused on the mother-child relationship. Most ego psychologists saw the structural point of view, Freud's latest metapsychology, as the most important. Some proposed that only the structural point of view be kept in metapsychology, because the topographical point of view made an unnecessary distinction between the unconscious and the preconscious (Arlow & Brenner) and because the economic point of view was viewed as redundant (Gill).
See also
Philosophy of mind
References
Further reading
1890s neologisms
Behavioural sciences
Philosophy of psychology
Psychoanalytic theory
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Social practice
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Social practice is a theory within psychology that seeks to determine the link between practice and context within social situations. Emphasized as a commitment to change, social practice occurs in two forms: activity and inquiry. Most often applied within the context of human development, social practice involves knowledge production and the theorization and analysis of both institutional and intervention practices.
Background in psychology
Through research, Sylvia Scribner sought to understand and create a decent life for all people regardless of geographical position, race, gender, and social class. Using anthropological field research and psychological experimentation, Scribner tried to dig deeper into human mental functioning and its creation through social practice in different societal and cultural settings. She therefore aimed to enact social reform and community development through an ethical orientation that accounts for the interaction of historical and societal conditions of different institutional settings with human social and mental functioning and development.
As activity
Social practice involves engagement with communities of interest by creating a practitioner-community relationship wherein there remains a focus on the skills, knowledge, and understanding of people in their private, family, community, and working lives. In this approach to social practice, activity is used for social change without the agenda of research. Activity theory suggests the use of a system of participants that work toward an object or goal that brings about some form of change or transformation in the community.
As inquiry
Within research, social practice aims to integrate the individual with his or her surrounding environment while assessing how context and culture relate to common actions and practices of the individual. Just as social practice is an activity itself, inquiry focuses on how social activity occurs and identifies its main causes and outcomes. It has been argued that research be developed as a specific theory of social practice through which research purposes are defined not by philosophical paradigms but by researchers' commitments to specific forms of social action.
Areas of interest
Education
In education, social practice refers to the use of adult-child interaction for observation in order to propose intentions and gauge the reactions of others. Under social practice, literacy is seen as a key dimension of community regeneration and a part of the wider lifelong learning agenda. In particular, literacy is considered to be an area of instruction for the introduction of social practice through social language and social identity. According to social practice in education, literacy and numeracy are complex capabilities rather than a simple set of basic skills. Furthermore, adult learners are more likely to develop and retain knowledge, skills, and understanding if they see them as relevant to their own problems and challenges. Social practice perspectives focus on local literacies and how literacy practices are affected by settings and groups interacting around print.
Literature
As literature is repeatedly studied in education and critiqued in discourse, many believe that it should be a field of social practice as it evokes emotion and discussion of social interactions and social conditions. Those that believe literature may be construed as a form of social practice believe that literature and society are essentially related to each other. As such, they attempt to define specific sociological practices of literature and share expressions of literature as works comprising text, institution, and individual. Overall, literature becomes a realm of social exchange through fiction, poetry, politics, and history.
Art
Social practice is also considered a medium for making art. Social practice art came about in response to increasing pressure within art education to work collaboratively through social and participatory formats from artists' desires and art viewers' increasing media sophistication. "Social practice art" is a term for artwork that uses social engagement as a primary medium, and is also referred to by a range of different names: socially engaged art, community art, new-genre public art, participatory art, interventionist art, and collaborative art.
Artists working in the medium of social practice develop projects by inviting collaboration with individuals, communities, institutions, or a combination of these, creating participatory art that exists both within and outside of the traditional gallery and museum system. Artists working in social practice art co-create their work with a specific audience or propose critical interventions within existing social systems that inspire debate or catalyze social exchange. Social practice art work focuses on the interaction between the audience, social systems, and the artist through topics such as aesthetics, ethics, collaboration, persona, media strategies, and social activism. The social interaction component inspires, drives, or, in some instances, completes the project. Although projects may incorporate traditional studio media, they are realized in a variety of visual or social forms (depending on variable contexts and participant demographics) such as performance, social activism, or mobilizing communities towards a common goal.
References
The arts
Human development
Social psychology concepts
| 0.778273 | 0.959996 | 0.747138 |
New York State Department of Mental Hygiene
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The Department of Mental Hygiene (DMH) is an agency of the New York state government composed of three autonomous offices:
the Office of Addiction Services and Supports (OASAS)
the Office of Mental Health (OMH)
the Office for People With Developmental Disabilities (OPWDD)
These offices are headed up by a commissioner who also serves on a council that performs inter-office coordination. Their regulations are compiled in title 14 of the New York Codes, Rules and Regulations.
Mental health
The majority of the public mental health system is in voluntary outpatient programs, the largest and most used being clinic treatment services. Inpatient care is provided mainly by homeless shelters, supplemented by the general hospital network, jails, and state psychiatric centers. 45–57% of New York mental health consumers use Medicaid, which is the largest single source of funding.
The Office of Mental Health (OMH) is responsible for assuring the development of comprehensive plans, programs, and services in the areas of research, prevention, and care, treatment, rehabilitation, education, and training of the mentally ill. Programs include inpatient, outpatient, partial hospitalization, day care, emergency, and rehabilitative treatments and services. OMH regulates and licenses private mental health services, such private psychiatric centers, clinics, and treatment facilities, including those in hospitals and schools. OMH also regulates residential treatment facilities for children and youth operated by nonprofit corporations. The public hospitals in the department are listed below, though there are many other private facilities; the New York State Psychiatric Institute and Nathan Kline Institute for Psychiatric Research are medical research institutes. The New York State Incident Management and Reporting System (NIMRS) is used by providers for reportable incidents.
OMH provides funding for eligible workforce development initiatives of licensed providers. Funding comes from federal Community Mental Health Services Block Grants and the enhanced Federal Medical Assistance Percentages program, more recently from e.g. the CRRSAA and American Rescue Plan Act of 2021 (COVID-19 stimuli packages), for targeted rate increases and recruitment and retention funds. The state FY 2024 budget also included funding for cost-of-living adjustments and expanded loan forgiveness for social workers and technicians. Many essential workers are still earning far below a living wage even after the COVID-19 pandemic. NYSDOL oversees the operation of local WIOA career centers (one-stop centers) that offer a range of employment and training services, including job search assistance, resume writing help, and access to job training programs.
The Behavioral Health Services Advisory Council (BHSAC) advises OMH by reviewing, monitoring, and evaluating the adequacy and delivery of services. The state Mental Hygiene Legal Service (MHLS) provides legal representation, advice, and assistance to mentally disabled persons under the care or jurisdiction of state-operated or licensed facilities concerning their admission, retention, care, or treatment. In the State Legislature, the Senate Mental Health and Assembly Mental Health standing committees conduct legislative oversight, budget advocacy, and otherwise report bills on the services, care, treatment, and advocacy for individuals with various disabilities, while the Senate Health and Assembly Health standing committees focus on healthcare facilities operations and services delivery more generally.
Addiction
The Office of Addiction Services and Supports (OASAS) provides funding, technical assistance, and oversight to a network of over 1,300 community-based addiction treatment programs, as well as 12 state-operated addiction treatment centers.
Statewide Health Information Network
The Statewide Health Information Network for New York (SHIN-NY, pronounced "shiny") is a health information exchange that allows healthcare providers to access and share patient data, managed by the nonprofit New York eHealth Collaborative. The Regional Health Information Organizations include:
Hixny in the Hudson Valley, Capital Region, and parts of the Southern Tier and North Country
Healthix in Greater New York
BronxRHIO in The Bronx
Rochester RHIO in Rochester, the Finger Lakes, and Southern Tier
HEALTHeLINK in Buffalo and Western New York
HealtheConnections in Central New York and the Southern Tier
History
In 1836–1843 the State Lunatic Asylum at Utica (Utica State Hospital) was established, and in 1865–1869 the Willard Asylum (Willard State Hospital) was established for the incurably insane and mentally ill paupers in the poorhouses. Throughout the late 18th and most of the 19th centuries, families and county poorhouses provided care to the mentally disabled, but in 1890 the State Care Act made the state responsible for the pauper insane. In 1909 the Insanity Law was consolidated in chapter 27 of the Consolidated Laws of New York.
The department was established in 1926–1927 with the original name being Office of mental hygiene; as part of a restructuring of the New York state government, and was given responsibility for people diagnosed with mental retardation, mental illness or epilepsy. Dr. Frederick W. Parsons was appointed the first department commissioner in January, 1927. He was replaced by Dr. William J. Tiffany in 1937, who then resigned in 1943 over an investigation into handling of an outbreak of amoebic dysentery at Creedmoor State Hospital. By 1950, the department had grown into the largest agency of the New York state government, with more than 24,000 employees and an operating cost exceeding a third of the state budget. The state acceded to the Interstate Compact on Mental Health in 1956.
The Office of Alcoholism and Substance Abuse was transferred from the New York State Department of Health to the Department of Mental Hygiene in 1962. In 1972 the Mental Hygiene Law was revised and reenacted. In 1978, the Department of Mental Hygiene was reorganized into the autonomous Office of Mental Health (OMH), Office of Alcoholism and Substance Abuse, and the Office of Mental Retardation and Developmental Disabilities (OMRDD). These three offices are headed up by a commissioner who also serves on a council that performs inter-office coordination. In 2010 the OMRDD became the Office for People With Developmental Disabilities (OPWDD). In 2019 the Office of Alcoholism and Substance Abuse became the Office of Addiction Services and Supports (OASAS).
Commissioners
DMH
1927–1937, Frederick W. Parsons
1937–1943, William J. Tiffany
1943–1950, Frederick MacCurdy
1950–1954, Newton Bigelow
1955–1964, Paul H. Hoch
1966–1974, Alan D. Miller
1975–1978, Lawrence C. Kolb
OMH
1978, James A. Prevost
1983, Stephen Katz
1988, Richard C. Surles
1995, James Stone
2007, Michael Hogan
2014, Ann Marie T. Sullivan
OPWDD
1975 (1978), Thomas Coughlin III (initially as Deputy Commissioner for Mental Retardation)
1980, James E Introne
1982, Zymond L. Slezak
1983, Arthur Y. Webb
1990, Elin M. Howe
1993, Thomas A. Maul
2007, Diana Jones Ritter
2011, Courtney E. Burke
2013, Laurie Kelley
2014 - 2018, Kerry Delaney (acting)
2019, Theodore A. Kastner
2021, Kerri E. Neifeld
OASAS
1990 (1992), Marguerite Saunders (initially as Director of the Division of Alcoholism and Alcohol Abuse)
1996, Jean Somers Miller
2004, William Gorman
2007, Karen Carpenter-Palumbo
2011, Arlene González-Sánchez
2021, Chinazo Cunningham
See also
New York State Department of Health
New York City Department of Health and Mental Hygiene
References
Further reading
External links
New York State Office of Mental Health (OMH)
Office of Mental Health on DATA.NY.GOV
New York State Office of Mental Health recipient profile on USAspending.gov
OMH contracts on Open Book New York from the NYS Department of Audit and Control
New York State Office of Addiction Services and Supports (OASAS)
Office of Addiction Services and Supports on DATA.NY.GOV
OASAS contracts on Open Book New York from the NYS Department of Audit and Control
New York State Office for People With Developmental Disabilities (OPWDD)
Office for People With Developmental Disabilities on DATA.NY.GOV
OPWDD contracts on Open Book New York from the NYS Department of Audit and Control
Mental Hygiene Law (MHY) as amended in the Consolidated Laws
Public Health Law (PBH) as amended in the Consolidated Laws
Department of Mental Hygiene in the New York Codes, Rules and Regulations (NYCRR)
Mental Health, Alcoholism And Substance Use Disorders, and Health committees of the NYS Senate
Mental Health, Alcoholism and Drug Abuse, and Health committees of the NYS Assembly
New York (state) government departments
State law enforcement agencies of New York (state)
Mental health organizations based in New York (state)
1927 establishments in New York (state)
Government agencies established in 1927
State departments of health of the United States
New York State Department of Mental Hygiene
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Ulysses syndrome
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Ulysses syndrome (immigrant syndrome of chronic and multiple stress) is an atypical set of depressive, anxious, dissociative, and somatoform symptoms that results from being exposed to extreme levels of stress unique to the process of modern migration. Rather than a mental disorder, this syndrome is a natural reaction to toxic levels of stress seen in migrants who are otherwise in normal mental health.
Signs and symptoms
The Ulysses syndrome has both physical and psychological symptoms. These include migraines, insomnia, recurrent worrying, tension, nervousness, irritability, disorientation, fear, fatigue, sadness, gastric pain, bone pain, low self-esteem, increased tobacco and alcohol consumption, and decreased productivity. A lack of social support or access to appropriate medical care may aggravate these symptoms. In some occasions, patients with Ulysses syndrome are mistakenly diagnosed with another medical condition which can further impede recovery.
Causes
Migration in the 21st century has occurred in the context of unprecedented volatility, conflict, and suffering. There are currently more forcibly displaced individuals in the world than at any other time in history, including 22.5 million refugees, 40.3 million internally displaced peoples, and 2.8 million asylum-seekers in 2016. Forced migration has profound impacts on individuals and families as their lives change suddenly and dramatically. Experiences of modern migrants include the separation of families, dissolution of communities by conflict and disaster, exposure to exploitation, and violence. Migrants remain in prolonged periods of displacement with a median time of four years in exile.
Migrants often face multiple forms of uniquely intense stressors, such as the death of loved ones, lack of jobs and social support, difficulties in the migratory process, and loss of status and identity. Because many migrants lack access to healthcare in the receiving country, they are often unable to receive appropriate care and continually re-experience the mental trauma of these losses. The cumulative effect may create stress levels so intense that they exceed individuals' adaptive capacities and lead to a failure of the acculturation process. This aggravates other symptoms, including depression, anxiety, headaches, and pain.
Extreme stressors that put individuals at risk for Ulysses syndrome, called "Ulysses stressors", can broadly be characterized into four categories:
Forced loneliness:
Separation from family and homeland, especially if the immigrant left his or her spouse and children behind
Social and cultural isolation due to lack of language proficiency or familiar cultural and religious institutions
Racial discrimination and prejudice in the receiving country
Failure of migratory goals:
Sense of failure of original reasons for emigration
Pressure to earn enough money to support family back in the home country
Lack of opportunities to acquire appropriate legal documentation, obtain work permits, and secure non-exploitative quality jobs
Poor access to housing and health services,
Dangers of the journey:
Crowded rafts and boats without life jackets
Fear of arrest and deportation
Physical and sexual abuse
Struggle to survive:
Difficulties procuring basic necessities such as food, water, and shelter
Middle-aged and elderly adults are typically more strongly affected than younger people are because they experience a larger loss of status and social mobility, have fewer encounters with people outside of the community through school or work, and are less likely to be exposed to the receiving country's mainstream culture. Moreover, older immigrants typically have greater difficulty learning the receiving country's language, which may substantially impair their ability to understand and interact with the new culture.
Diagnosis
Ulysses syndrome is not a mental disorder, but rather a normal stress response by a healthy individual to an extreme situation that overwhelms the normal psychological mechanisms for coping. By definition, this syndrome cannot be diagnosed if another mental disorder is present. There is currently no DSM-5 criteria for this syndrome.
Although often falsely recognized as acute stress disorder, depression, adjustment disorder, or other mental disorders, Ulysses syndrome differs from these pathologies in important ways:
Acute stress disorder: Ulysses syndrome is brought about by chronic exposure to toxic stress, whereas the symptoms of acute stress disorder by definition are limited to one month.
Depression: Although depressed mood is common, Ulysses syndrome does not include many other cardinal symptoms of depression such as apathy or thoughts of death. Immigrants, unlike people suffering from depression, have the motivation to go forward and struggle in order to reunite with their families and have a better life, despite their current difficulties, and do not lose their interests. Rather, they try to maintain their social and professional activities.
Adjustment disorder: One of the central diagnostic criteria for adjustment disorder is distress that is out of proportion to the severity or intensity of the stressor or stressors. On the other hand, Ulysses syndrome is an appropriate response that manifests as anxiety, insomnia, sadness, etc., precisely due to the extreme nature of the stressors. Moreover, deterioration of social and occupational functioning, which is often present in adjustment disorder, does not occur in Ulysses syndrome.
Post-traumatic stress disorder: Both PTSD and Ulysses syndrome stem from a response to fear. However, disturbing thoughts or feelings about traumatic events as well as distress and avoidance of trauma-related cues do not occur in Ulysses syndrome, but does in PTSD, whereas stressors such as social isolation, lack of opportunities, discrimination, and prejudice are common for Ulysses syndrome and not for PTSD.
Although clinically distinct from mental health disorders, Ulysses syndrome exists on a spectrum between normal and disease. It can be understood as the extreme limit of normal mental functioning that can still be considered non-pathological. However, an individual with Ulysses syndrome is at greater risk of disease and indeed, at a certain point the stressors may become too intense such that a true clinical mental disorder such as depression or PTSD can develop.
Treatment
Because Ulysses syndrome is a stress response rather than a mental disorder, the natural response for an individual is to return to his or her normal state of health once the stressors are eliminated. Dr. Achotegui, who first described Ulysses syndrome, makes the analogy to a stalk of bamboo that bends in the wind. Just like bamboo will bend but not break, those who are exposed to Ulysses stressors are brought to the brink of mental instability and are made more vulnerable to mental disorders, but do not have a disorder yet. When the wind subsides, the bamboo will spring back to its normal state, just as those who face these stressors will return to their normal selves if and when the stressors resolve.
Preventive measures that may help reduce Ulysses syndrome generally revolve around building mental resilience, such as finding closure after losing loved ones, embracing changes in identity as an opportunity for growth, talking with others who have undergone similar experiences, re-evaluating expectations to be more realistic, and learning to live in the present rather than dwell too deeply in nostalgia.
One proposed therapy leverages the ability of community health workers CHWs) to connect with hard to reach populations such as displaced migrants. CHWs better understand the local culture and traditions and may, with the appropriate training, be able to engage affected individuals more effectively. For instance, CHWs can often better advocate for migrant rights and connect migrant populations to the resources necessary to facilitate integration and build community, all of which helps reduce the extreme stressors that lead to Ulysses syndrome.
History
Dr. Joseba Achotegui from the Universitat de Barcelona coined the term Ulysses syndrome in 2002. It was named after the ancient Greek hero, Odysseus (Ulysses in Latin), who suffered involuntary migration and travelled for 10 years through the Mediterranean to come back home from the decade-long Trojan War. The hardships of his journey are compared to the ones of contemporary migrants, who must struggle with intensely stressful, novel situations in isolation and with little help. Scarcity of their resources makes it impossible to cope with and successfully adapt to the unfamiliar environment of the receiving country, which in turn leads to experiencing a range of detrimental symptoms.
There are accounts that cited the Canadian Mercer Rang as the originator of the term. However, Rang described a different condition in 1972, one that is characterized by ill or side effects of extensive diagnostic investigations because of a false-positive result of laboratory screening. Here, the patient is likened to Ulysses as he embarks on a journey that brings more suffering than he had to begin with.
Alternative use of Ulysses syndrome
The term Ulysses syndrome has alternatively been used to refer to the psychological and physical sequelae of misdiagnosis due to a false positive result. For instance, a patient who complains of low risk chest pain may be referred for further cardiac work-up by an overcautious physician. These tests in turn may give a positive result due to high sensitivity, which subjects the patient to further testing that ultimately proves to be unnecessary. Victims of this condition experience the stress of being diagnosed with a condition they do not have as well as the physical trauma of invasive testing.
There is currently no consensus on the definitive use of the term “Ulysses syndrome”. Nevertheless, Ulysses syndrome as it is used to describe the effects of chronic extreme stress in migrant populations is more in line with the definition of a syndrome as used in the medical field, i.e. a set of signs and symptoms that constitute a disease. Moreover, because migrants who experience chronic stress and fear are frequently incorrectly diagnosed with depression or anxiety, it encapsulates the alternative definition of this condition.
References
External links
Ulysses syndrome National Center for Biotechnology Information.
Post-traumatic stress disorder
Psychopathological syndromes
| 0.76642 | 0.97476 | 0.747076 |
Achenbach System of Empirically Based Assessment
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The Achenbach System of Empirically Based Assessment (ASEBA), created by Thomas Achenbach, is collection of questionnaires used to assess adaptive and maladaptive behavior and overall functioning in individuals. The system includes report forms for multiple informants – the Child Behavior Checklist (CBCL) is used for caregivers to fill out ratings of their child's behavior, the Youth Self Report Form (YSR) is used for children to rate their own behavior, and the Teacher Report Form (TRF) is used for teachers to rate their pupil's behavior. The ASEBA seeks to capture consistencies or variations in behavior across different situations and with different interaction partners.
The ASEBA is used in a variety of settings, including mental health, school, research, and forensic settings.
The ASEBA exists for multiple age groups, including preschool-aged children, school-aged children, adults, and older adults. Scores for individuals in each age group are norm-referenced. The ASEBA has been translated in one hundred languages, and has a variety of multicultural applications. Each report form in the ASEBA System has 113 items, but there is not a one-to-one correspondence between each individual item across the different report forms.
History
The ASEBA was created by Thomas Achenbach in 1966 as a response to the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). This first edition of the DSM contained information on only 60 disorders; the only two childhood disorders considered were Adjustment Reaction of Childhood and Schizophrenic Reaction, Childhood Type.
Achenbach used machine learning and principal component analysis when developing the ASEBA in order to cluster symptoms together when forming the assessment's eight categories. This approach ignored the syndrome clusters found in the DSM-I, instead relying on patterns found in case records of children with identified psychopathologies. As a result of this, the ASEBA was able to identify more syndromes than originally identified in the DSM-I. Additionally, this reliance on real-world case records allows the ASEBA to interpret scores in relation to age, gender, and ethnic/racial norms, as symptom/disorder severity and meaning vary across cultures.
Components
The ASEBA consists of many self-report assessments for individuals between the ages of 18 months and 90 years. Below is a list of the self-report assessments currently offered:
Preschool-aged assessments:
Child Behavior Checklist for Ages1½-5 (CBCL/1½-5) – To be completed by the child's parent or guardian, as the child is too immature to complete the assessment themselves.
Language Development Survey (LDS) – A subsection of the CBCL/1½-5. This form is completed by the child's parent or guardian and assesses whether the child's vocabulary is delayed relative to norms.
Caregiver-Teacher Report Form (C-TRF) – To be completed by the child's daycare provider or preschool teacher.
Test Observation Form (TOF) – For ages 2 through 18.
School-age assessments:
Child Behavior Checklist for Ages 6-18 (CBCL/6-18)
Teacher's Report Form (TRF)
Youth Self-Report (YSR)
Brief Problem Monitor for Ages 6-18 (BPM-P/6-18, BPM-T/6-18, or BPM-Y/6-18, depending on whether the form is completed by the teacher, parent, or youth)
Semistructured Clinical Interview for Children and Adolescents (SCICA)
Direct Observation Form (DOF) – For ages 6 through 11.
Adult assessments:
Adult Self-Report (ASR) – To be completed by the adult. This assesses the adult's adaptive functioning, strengths, and problems.
Adult Behavior Checklist (ABCL) – To be completed by a known individual of the adult, meant to reflect answers provided on the ASR.
Brief Problem Monitor for Ages 18-59 (BPM/18-59)
Older adult assessments:
Older Adult Self-Report 60-90+ (OASR
Older Adult Behavior Checklist 60-90+ (OABCL)
The ASEBA also provides multicultural supplements for the provided self-report assessments, allowing for comparison of selected scores with the norms from the non-standard culture. Additionally, the ASEBA forms have been translated into over 110 languages, although not every form is available in each language.
Scales and scoring
Each ASEBA assessment consists of 113 items, which are used to provide a score report of 7 to 8 scales. Each item is not directly correlated with a specific scale, as the assessments recognize patterns of syndromes as belonging to a specific scale. These include:
The score reports list the individual's total score, as well as their t-score and the related percentile. The score reports also include Internalizing, Externalizing, and Total Problems scales.
References
External links
Questionnaire construction
Psychological tests and scales
| 0.761448 | 0.981096 | 0.747053 |
Vineland Adaptive Behavior Scale
|
The Vineland Adaptive Behavior Scale is a psychometric instrument used in child and adolescent psychiatry and clinical psychology. It is used especially in the assessment of individuals with an intellectual disability, a pervasive developmental disorder, and other types of developmental delays.
History
The Vineland Adaptive Behavior Scale was first published in 1984, as a revision of the Vineland Social Maturity Scale, which is named after Vineland Training School in Vineland, New Jersey where Edgar Doll had developed it.
In 2005, Vineland-II was published, which added a 4th domain of motor skills, and in 2016 Vineland-3 was published, where the overall number of items on the scale increased by 34%.
Purpose
The Vineland Adaptive Behavior Scale assesses a person's adaptive level of functioning by standardized interview of the person or their caregiver through their activities of daily living such as walking, talking, getting dressed, going to school, preparing a meal, etc. The original Vineland interview assessed three domains: communication, socialization and daily living, which correspond to the 3 domains of adaptive functioning recognized by the American Association on Intellectual and Developmental Disabilities namely conceptual skills (language and literacy, mathematics, time and number concepts, and self-direction), social skills and practical skills of daily living.
Limitations
Since no gold standard for evaluation of adaptive behavior exists, the test validity of this tool is unknown.
See also
Vineland Social Maturity Scale
References
Screening and assessment tools in child and adolescent psychiatry
Intellectual disability
| 0.764729 | 0.976745 | 0.746945 |
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