Posted by Admin on June 3rd, 2009
As workers in the field of child and family relationships we are now well versed in the fact and dynamics of child abuse and violence. However as both the professional world and the wider community have come to embrace the need to protect children and parent in positive ways, family violence has appeared in a new guise. This is the violence which occurs in families’ of children with acute behavioral problems and parents who are helpless in its grip. Such parents view themselves as less powerful than their children and respond to their child’s demands with escalating punishment and violence, impotent acquiescence or an oscillation between the two. Such escalations feed the parents’ sense of powerlessness, hopelessness and the belief that ‘nothing works’ and allows the child to make increasingly risky and self-destructive choices.
Enter Haim Omer who has taken the ideas of non-violent resistance as practiced by Mahatma Ghandi and Martin Luther King and applied them to families with children with aggressive or other acute behavioral problems. Originally developed in Israel, this parent focused approach is now being applied in centers in Germany, England, Switzerland and Holland. Yet however intuitively appealing an intervention may be it is only as good as its objective effectiveness. The paper by Weinblatt, U. and Omer, H. “Nonviolent Resistance: A Treatment for Parents of Children with Acute Behavioral Problems” addresses this question. This is an evaluative study of a five week parent training program in the approach which randomly assigned 73 parents into a treatment and wait list control group and took measures at pre-treatment, post-treatment and one month follow up. Parents who participated in the treatment ‘showed a decrease in parental helplessness and escalatory behaviors and an increase in perceived social support’ compared to the waitlist control group. Intervention also resulted in the parents reporting a decrease in the children’s negative behaviors. One month follow-up demonstrated maintenance of change in relation to parental helplessness, parental permissiveness and child behavior. While the authors are careful to recognize the limitations of a study which was of limited duration and based on parental self report, the results are encouraging enough to warrant further exploration and application of this creative and respectful approach to extremely difficult children for whom traditional behavioral modification approaches have proved ineffective.
Weinblatt, U and Omer, H (2008) “Nonviolent Resistance: A Treatment for Parents of Children with Acute Behavioral Problems” Journal of Marital and Family Therapy, 34,1, 75-92 The answer : Each produced remarkable outcomes in seemingly intractable circumstances using methods of non-violent resistance
Special Workshop August 7th presented by Catherine Sanders & Malcolm Robinson
THE APPLICATION OF NONVIOLENT RESISTANCE (NVR) TO WORK WITH ANGRY, CONTROLLING AND AGGRESSIVE CHILDREN
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Posted by Admin on May 10th, 2009
Clearly affairs and there sorry fallout sell newspapers. In Adelaide, the decision by Mel Gibson’s wife to apply for divorce on account of his reputed infidelity has made front page headlines. This is possibly because their relationship is reported to have begun in this city but the fascination with the topic is broader than this. For therapists the private disclosure of an affair by one person where a couple has attended for marital therapy leaves the practitioner with a particularly difficult clinical and ethical dilemma. Should one urge the errant party to disclose to their partner or is it better to ‘leave well alone’ particularly as we know the distress that such a revelation will no doubt have?
This is the subject addressed by Butler, Harper and Seedall in their paper ‘Facilitated Disclosure versus Clinical Accommodation of Infidelity Secrets: An Early Pivot Point in Couple Therapy’, published in the Journal of Marital and Family Therapy January 2009, Vol. 35, No. 1, 125–143. According to an American National survey of marital and family therapists, 96% stated that they would maintain a confidentially disclosed infidelity secret. These authors suggest that the issue needs to be more fully explored and that the ethical question be addressed by using theoretical concepts of attachment and intimacy in a decision to facilitate disclosure as opposed to agreeing to support secrecy. In particular they argue that the infidelity itself ‘represents a fundamental contradiction to one’s confidence in the partner “being for” the other in their couple relationship. Instead infidelity looks like one’s partner “being for” himself or herself or another, in opposition to one’s own well being and expectations. Further, the secret keeping is an obstruction to both parties attachment intimacy with the secreted parts of the self representing a disconnection resulting in a relationship that is a ‘staged façade of intimacy rather than a real-life enactment of intimacy’. They argue that neither attachment intimacy nor attachment security can be achieved by maintaining the secret and that while disclosure will also devastate it allows the possibility for the ‘healing ordeal’ that secrecy does not.
This is a complex paper and requires attention in it’s reading but it is well worth the effort and by the end it is hard to disagree with the authors contention that ‘facilitating disclosure of infidelity, although difficult and demanding represents the most ethical action and offers the best prospect for a renewed and vital intimate attachment relationship.’
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Posted by Admin on April 5th, 2009
Every now and then a movie is released which appears to touch a raw nerve and in doing so generates widespread interest and debate. This is the case with the recently released “The Reader” starring Kate Winslet as a former Nazi prison guard who following the war develops a sexual relationship with a then 15 year-old boy. Later she is brought to trial for war crimes and the boy, now a young law student, faces his own moral dilemma as he watches the justice process unfold. This post is not a movie review but rather addresses the key question the film raises of moral equivalence, the position that the German’s who blindly followed orders and committed such atrocities were victims just as the Jews were victims.Such a position seems intuitively unpalatable and certainly roused the ire of Tom Bower who in writing for the Sunday Times under the banner “Monsters Without Remorse” compares this woman with two real life convicted Nazis “Both would have undergone similar grooming. Both chose to obey orders and become murderers. Quite rightly both were punished”.
Whilst this is a reasonable conclusion to draw at one level, it may be too simplistic at another. In characterizing them, Kate Winslet’s character and the two real life convicted Nazis, as “monsters” (which they most likely were) does this protect the rest of us from facing a more deeply troublesome question, Could I too be such a monster? and What Does it Mean for Now?
This former is in effect the question addressed by Philip Zimbardo (2007) in his book “The Lucifer Effect: Understanding How Good People Turn Evil”. Zimbardo became famous for the Stanford Prison Experiment where psychologically healthy, randomly assigned college students transformed into brutal guards and traumatized prisoners in a matter of days, when placed in a simulated prison. Zimbardo states “I realized that it was I, along with my research team, who was responsible for the system that made the situation work so effectively and so destructively. We failed to provide adequate top-down constraints to prevent prisoner abuse and we set an agenda and procedures that encouraged a process of de humanization and de-individuation that stimulated guards to act in creatively evil ways.”
In taking Zimbardo seriously we are confronted with the potential in all of us to behave in terrible ways if placed in a context without appropriate constraints on the one hand and clear and brutal role expectations on the other. Zimbardo sketches the deep psychological and social tension between personal responsibility and systemic constraint. Does one negate the other? The lesson of Abu Ghraib is clearly that the system itself can create its own ‘monster’. So often the system washes it own hands and absolves itself of all responsibility by placing the full burden of responsibility for such monstrous acts on the individual. Of course systemic responsibility does not absolve the individual either.
What does this mean for us and now? We are no doubt entering a time of economic hardship when operating from a position that is fair and just for all will become increasingly expensive for many. A time when agreeing to sacrifice constraints which keep us ‘good’ and civilized may be tempting if they offer security and comfort for ourselves and those nearest to us. While we have the freedom we do in a democracy like ours, we should be alert to agreeing to decisions which limit the choices of others, which dehumanize those in our midst and which elect others to positions of power who support these ideas. We should act while we can.
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Posted by inmyopinion@bower on March 27th, 2009
Impaired practitioners are those who are unable to fulfil professional or personal responsibilities because of psychiatric illness, alcoholism or drug dependency. In Australia most of the literature is from professional registration boards about procedures and complaints panels, not about prevalence, prevention, assistance or intervention. In exploring the literature it was a surprise to discover that there is almost no reference to impaired psychologists and counsellors while there is more available around impaired physicians and psychiatrists. I suspect the dearth of information is not because psychologists are immune to mental health problems. The small amount of literature, from America in the mid 1990’s, suggests that they are at risk of anxiety, depression, alcohol problems and relationship difficulties.
Mental illness is stigmatising. and those working in mental health are often the most inclined to stigmatise their colleagues. There is often the belief that if a mental health problem is admitted then you might as well retire as you are ‘no good to anyone anymore.’ This personal and professional stigmatisation adds to stigma already present in the community. Then there is the fact that practitioners have a tendency to either protect or ignore impaired practitioners – I have experienced opposition to getting appropriate assistance for co workers on a number of occasions – and the delay in treatment causes significant problems in relationships and professional reputation, not to mention personal distress. The impact on family is often not seen by co-workers, but is significant.
Working in the mental health arena is stressful, and primary and secondary prevention of mental health problems is important. Early warning signs include irritability, social withdrawal, reduced quality of work, reduced productivity, emotional exhaustion and fatigue, isolation, disillusionment, job relocations and sleep problems.We know these things for our clients but are reluctant to turn the mirror on ourselves and our colleagues. Information and education about burnout, about building resilience, about the need for a general practitioner, as well as confidential assistance programs and rehabilitation programs are all important in looking after ourselves and our colleagues.
References
Wilson A, Rosen A, Randal P, Petherbridge P, Codyre D, Barton D, Norrie P, McGeorge P, Rose L. Psychiatrically impaired medical practitioners: an overview with special reference to impaired psychiatrists . Australasian Psychiatry 2009 17:1 6-10
Wilson A, Rosen A, Randal P, Petherbridge P, Codyre D, Barton D, Norrie P, McGeorge P, Rose L. Psychiatrically impaired medical practitionersbetter care to reduce harm and life impact, with special reference to impaired psychiatrists. Australasian Psychiatry 2009 17:1 6-10
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Posted by Admin on March 23rd, 2009
The calm of a therapists office seems miles from the tension of a hostage situation yet in both places the power of relationship, communication and strategy are primary. Sokas and Van Zandt (1986) paper “Hostage Negotiation: Law Enforcements Most Effective Non-Lethal Weapon” provides an instructive, easily read overview of an area largely unfamiliar to clinicians. The paper commences with a short history dating the beginning of modern hostage negotiations from the 1972 Olympic Games in Munich when a group of Palestinian terrorists took 11 Israeli athletes as hostages, culminating in the deaths of 22 people.
The authors categorize hostage taking along a continuum from trapped criminal incidents where a person is trapped by police in the course of committing an offence to acts of terrorism. By far the biggest group, 59% involve a person suffering a mental disorder, (depression, bi-polar disorder, schizophrenia or other psychoses) or emotional difficulties as a result of personal problems or family disputes. Drug and alcohol problems may also play a significant role. While clinicians may be consulted the authors suggest that direct intervention may in fact exacerbate the situation where the hostage taker has a history of unsuccessful experiences in the mental health field.
Despite the differences, many hostage situations share central dynamic features. A key aspect is that these are instrumental or triadic arrangements where “the hostage taker attempts to use the hostage to coerce or communicate with a third party, who inevitably becomes a part of the hostage incident, even at a distance” This essentially systemic understanding locates the negotiator within a web of relationships which must be understand in all their complexity if a positive outcome is to be achieved. This can be especially challenging when the hostage taker is delusional and the target or audience for the demand does not exist or has no real relationship to those involved. The paper describes a number of recognizable patterns which may apply in these situations and indicators when a negotiation is going poorly or well. It concludes with comments about selection and training of negotiators and future developments.
Reading this paper left me with a better informed respect for the work done by our police negotiators who, unlike the therapist ensconced in their office, has the added burden that, should their work go awry blood, not tears may be shed.
Sokas, D and Van Zandt, C (1986) “Hostage Negotiation: Law Enforcements Most Effective Non-Lethal Weapon” Behavioral Science and the Law Vol 4, No 2 pp 423-435
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Posted by Admin on March 14th, 2009
In our sex saturated world it should come as little surprise that research confirms that a satisfying sexual relationship is intricately connected to relationship satisfaction. As Timm (2009) says in her paper “Do I Really Have to Talk About Sex? Encouraging Beginning Therapists to Integrate Sexuality into Couples Therapy” ‘conventional wisdom tells us that sex is only 5% of a relationship when its going well and 95% when it is not’ perhaps because it is the physical expression of the primary emotional bond. What may be more surprising is how absent the discourse about sex is in couple and relationship therapy. Timm proposes a number of explanations for this including a lack of formal training with many courses having no requirement for specific education on the topic and neglect in supervision. Another crucial element is the self of the therapist. It is clear that the more comfortable a practitioner is to discuss sexual issues the more likely they are to include the topic in the therapeutic conversation. Messages received in the family of origin, the current quality of the practitioners’ own sexual relationship and their knowledge about sexuality all contribute to their comfort. A belief that raising the topic would embarrass clients can also act as a constraint, yet it is clear that the therapists’ ability to speak freely is liberating and normalizing for clients.
Timm offers a reassuring guide to the nervous therapist “The good news is that couples therapists do not need extensive, formal sex therapy training to address issues of sexuality in their clients’ relationships. This paper educates about the PLISSIT Model, offers specific suggestions to increase the therapist’s comfort level, provides basic questions to ask every couple, and recommends more detailed sexual history questions to use when relevant.”
The paper then proceeds to fulfill all its promises explaining the PLISSIT model ( Permission Giving, Limited Information, Specific Suggestions and Intensive Therapy) a graded series of interventions which allow even the most junior and nervous therapist to offer something to their client. In addition the author provides a series of specific questions to ask when exploring a couple’s sexual relationship and an extensive bibliography of resources for both the practitioner and client. By the end all are liberated and well informed!
Timm (2009) “Do I Really Have to Talk About Sex? Encouraging Beginning Therapists to Integrate Sexuality into Couples Therapy Journal of Couple & Relationship Therapy, 8:15–33
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Posted by psych@bower on February 17th, 2009
Over the past week we have watched first with disbelief then horror and grief as the full extent of the fires that have swept across the country have become known. So when an evening talk show host announced that they had decided to postpone their usual program to discuss the bushfires I sat down to watch. The host explained that they had invited four people into the audience to describe their experiences and a panel to answer questions. It was with growing unease that I watched him request they describe ‘what had happened to them’ barely five days later. One guest, an older woman initially appeared silenced by his question and then embarked on a long and discursive description of her day leading up to the fires and the relevance and importance of all she had lost. This was not what the host had in mind as he interrupted and directed her narrative in an effort to tailor it to television. The program moved on to the experts debating policy, who was to blame and whether we were altruistic enough to support those in need. All the while the four guests sat, as if immobilized in their seats. It didn’t feel right and my ease did not dissipate with time. Instead it lead me to the Australian Psychological Societies website to seek advice.
I was struck by the comment “It is not useful, and may even be harmful, to directly encourage a disaster survivor to ventilate their responses in the initial phase. If a person has a desire to discuss their experiences, it is useful to provide them with support to do this but in a way that does not encourage disclosure beyond the level that they wish to discuss.” What I had observed was exactly in opposition to this.
Instead the recommendation is to provide psychological first aid (Adapted from Substance Abuse and Mental Health Services Administration (SAMHSA) (2007). Psychological first aid: A guide for emergency and disaster response workers. Washington, DC: U.S. Department of Health and Human Services http://www.samhsa.gov/) The key elements as described on the APS website are to:
Promote safety
· Help people meet basic needs for food and shelter, and obtain emergency medical attention.
Provide repeated, simple and accurate information on how to get these basic needs.
Promote calm
· Listen to people who wish to share their stories and emotions, and remember that there is no right or wrong way to feel.
· Be friendly and compassionate even if people are being difficult.
· Offer accurate information about the disaster or trauma and the relief efforts underway to help victims understand the situation.
Promote connectedness
· Help people contact friends and loved ones.
· Keep families together. Keep children with parents or other close relatives whenever possible.
Promote self-efficacy
· Engage people in meeting their own needs.
Promote help
· Find out the types and locations of government and non-government services and direct people to those services that are available.
· When they express fear or worry, remind people (if you know) that more help and services are on the way.
This makes sense where the talk show did not. I can only hope the guest’s television appearance has not magnified their trauma.
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Posted by inmyopinion@bower on December 22nd, 2008
Many of us love Christmas but those who work in the counselling and psychotherapy field know it can be a difficult time for even the most cheerful. Take yourself. There is all the pressure of celebration which begins with the school carol service ( notice it’s always the same night as a long standing professional commitment), proceeds seamlessly through Christmas get togethers and thank you’s with colleagues, the staff celebration and finally our own family and friends gatherings. That doesn’t take into account the task of Christmas shopping, which is fun but have you noticed that some people end up with multiple gifts while others seem impossible to buy for? No wonder we come to Christmas Day, ready for a break from all responsibility including our professions. we just want a holiday!
We know that we are the lucky ones for Christmas can be lonely and difficult time for many of our clients. Families who have been estranged all year will yearn for reconciliation and the fantasy Christmas celebration, only to be dissappointed when the reality is experienced. Others will be experiencing the pain of family separation and seeing children for only half their usual celebration. For some, Christmas will be spent alone at a time when EVERYONE else is with loving family. No wonder this is a time when life can become too painful to bear. So, at a time when we as helpers most need a rest, our clients need support.
It is this reality that has made us reconsider our services over the Christmas, New Year break. We have decided to remain open and to offer appointments to our own clients and also to others whose usual practitioner may be unavailble. For the latter we will meet their immediate request and then redirect them back to their previous practitioner when they are again available with the offer of liason to ensure continuity of care. We may not be able to fill everyone’s stocking but even a little may help.
Bower Place is Opening Hours during the Holidays
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Posted by psych@bower on December 12th, 2008
When confronted with the distressing, horrifying and often inexplicable fact of child abuse many practitioners find themselves overwhelmed by the horror and enormity of the situation. We find ourselves searching for guidance and clarity to make sense of the matter before us and to guide our practice in order to achieve the best possible outcome for the child and their family.
It is with great relief to encounter two chapters written by Arnon Bentovim which promise the clarity and direction we crave. The paper “Physical and Sexual Abuse” which appears in a text on Child Psychiatry published by Cambridge University Press in 2006, clearly identifies the different forms of abuse against children, and aims to identify coherent themes which may influence the way that professionals act. Further it outlines the appropriate role and tasks of the treating professional. The paper takes a fully systemic view as it clearly defines different forms of abuse, the impact of such experiences and guidelines for interviewing and management. At each stage the practitioner is reminded that abuse occurs in a broad context inclusive of the child, their family, school, welfare and legal systems.
A second paper “Interventions: What Can Services Achieve Which is Useful and Effective?” appeared in a text on Evidence Based Practice in the Welfare Field published in 2007. This chapter explores “levels of intervention, specific ways of helping children and young people recover from the effects of abuse and neglect and addresses which families, under which circumstances, might benefit from particular interventions.” It also details ‘core knowledge’ including assessment of the child’s needs and understanding of different types and severity of harm necessary for the practitioner to plan appropriate intervention. “The ultimate goal of intervening in the lives of children who need to be safeguarded is prevention. The aim is to prevent harm in the future, ensure children are wanted and cared for adequately, are protected and exposed to as few risks to their development as possible, and they live in a context where their needs are met. Adequate safeguards will make certain that they achieve their developmental potential. Through this approach the emotional and physical health of the present and future generations is assured.”
Both papers are clear, well written, thoroughly referenced and above all compassionate of all who find themselves caught in the horror that is child abuse.
December 18th 2008, Dr. Bentovim and Mrs Bentovim will be presenting on
The Journey To Recovery Safeguarding Children Living With Trauma And Family Violence.
To register click on the event or go to: http://seminars.bowerplace.com.au and find a list of all our coming classes and seminars.
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Posted by Admin on November 7th, 2008
It has long been recognized in both academic and clinical settings that mental health service use is related to a range of factors such as income, gender, pre-existing psychiatric disorder and lifetime exposure to traumatic events, and is not simply representative of need (i.e. the presence of a psychological disorder). Anderson and Newman (1973, 1995) propose a model of mental health service use that highlights the mediating role of both predisposing and enabling variables, as well as simple need.
Need factors, defined as both perceived and evaluated psychological functioning, are the most immediate cause and strongest predictor of mental health service use. Within the Australian population, for example, Parslow and Jorm (2000) found self-report measures of depression or anxiety and CIDI-diagnosed substance abuse disorder to be predictive of increased use. Enabling factors that predict mental health service use include cost of service (which relate to whether or not the individual has private health insurance), cultural appropriateness of the service, and level of awareness of the types and purpose of the services provided. Predisposing factors are the socio-cultural characteristics of an individual that exist prior to the development of an illness. Those with fewer psychosocial assets, pre-existing physical health problems and previous experience of mental health care are more likely to seek mental health assistance. Women and people who are single also report increased use. In traumatized populations, female trauma survivors have greater mental health service use than do male trauma survivors.
Mills, Van Hoof and MacFarlane (2008) examined Mental Health Service utilization prior to the introduction of the Medicare rebate within South Australian and found females had significantly higher rates of mental health service use that did males, irrespective of need.
The Australian Government’s 2006 expansion of Medicare rebates to mental health services has rightly received bipartisan support. It has also been eagerly embraced by private psychologists and other allied health workers, with a substantial increase in the number of practitioners providing Medicare related services. Given this increase, one would hope that those groups under-represented in the mental health system would start to increase their use of this more affordable system. However, two years on and Mental Health Council of Australia (MHCA) analysis obtained by AAP reveals that women remain twice as likely as men to access Medicare-subsidized mental health services.
Unfortunately, then, the removal of cost has done little to reduce other barriers that result in men using minimal levels of mental health services. Instead, this low use remains a systemic issue related to cultural norms around help seeking behaviors and the stigma attached to mental health. To put it bluntly, men are not meant to have these types of problems, and they are defiantly not meant to talk about them! This is further demonstrated in the low numbers of men working in the mental health system.
So how do we fix this? At its simplest, we need to be developing education programs for schools so that from a young age, mental health and help seeking behavior is destigmatised for the male of the species. Introducing a broad support system for mental health support is a wonderful initiative. However, to be fully effective it must be supported by systemic change.
At Bower Place, we are fortunate to have a single member of that rare species “the male psychologist”. However, a glance into Clinical Psychology lecture room quickly shows that unless something changes, he may be the last of a much needed dying breed.
References
Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. Winter 1973;51(1):95-124.
Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. Mar 1995;36(1):1-10.
http://www.mhca.org.au/documents/MHCAMBSV2lay08LRc.pdf Mills V, Van Hooff M, McFarlane AC. Predictors of Mental Health Service Utilisation in a Non-treatment Seeking Epidemiological Sample of Adults Exposed to Childhood Trauma. Aust N Z J Public Health (2008 in press).
Parslow RA, Jorm AF. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry. Dec 2000;34(6):997-1008.
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