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
          

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

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.

Paul, Michael and Wayne; three violent men whose histories are relayed by Carol Boland in her paper “Can Violent Men Change?” The stories of Paul and Wayne make chilling reading as two men from vastly different backgrounds that end up at the same psychological place where they attempt to murder their wives and children who have left them. Carol uses personality theory and in particular the theory of narcissism to explain how this could be. Paul grew up in a world where he could ‘do no wrong’ with a childhood that taught him no strategies to deal with what he perceived to be the ‘outrageous and unwarranted rejection’ of his abused wife’s decision to leave. By contrast Wayne’s childhood was dominated by abuse and humiliation and a powerful sense of shameful inadequacy with the result that he was hypersensitive to criticism and reacted violently. The humiliation implicit in his partners decision to leave him resulted in the same behavior as Paul.  

By contrast she presents the case of Michael, a man who has been equally violent yet is able to engage with the therapist and not only acknowledge his violence but act to change it.

Carol makes a cogent point. Violent men can change but ‘we need to be more skilled at recognizing who they are’. Central to this is understanding the quality of their own parenting  ‘particularly any information that helps us to understand what they internalized about personal responsibility and remorse’ For those who are steeped in defensive shame like Michael and Wayne it is impossible to predict whether they can respond. However initial screening to distinguish the still-reachable from the too-defended which both appeals to the man’s self-interest and rewards vulnerability and responsibility to change is crucial. In addition it is crucial that we warn the partners of violent men how they leave and be aware that a history of physical violence is no predictor. Never humiliate them, she warns, ‘if possible, simply leave when he is not around. ’She concludes by saying that anti-violence programs must be thoroughly and reliably assessed and that therapist should be unafraid to state that some men are unable or unwilling to change and that services must be provided to properly protect woman and children.
 

Boland, C. (2008) Can violent men change? Context: The Magazine for Family Therapy and Systemic Practice in the UK. 97: 6-9.

When people think about therapists working with abused children, they usually imagine child-friendly rooms with therapists gently encouraging the development of therapeutic alliances from which the children can begin to repair their psychological harm. The image relies on a number of assumptions and implies a number of possibilities: the child is able to access the therapist regularly and indefinitely, the therapeutic goal(s) are clear and achievable, and the children are eventually able to pour out their hearts with the conviction that the therapist can make it all better. Eventually, the image implies, the child will emerge from the therapeutic process either healed or with sufficient resilience to withstand whatever depredations or deprivations remain to be faced.

Sadly, therapy with these clients is rarely so straightforward. In this sometimes confronting but always-realistic presentation Carol will address many of the dilemmas therapists face in attempting to help their child clients. She will be starting from the following positions
1. The second most powerless person after the child client is the therapist

2. Before the therapist can hope to achieve any therapeutic change, he / she must negotiate a potential mine field of services and individuals with often competing or contradictory policies and agendas

In the political arena, South Australia remains steadfastly against the use of controlled crying. However, the debate has been refuelled since the Victorian government announced plans to train 200 maternal and child health nurses in the controversial method. Not only has the controversy fuelled debate among parents and professionals, log onto any parenting forum and you will see the sparks fly from both camps, but the baby sleep game is becoming big business. There is a growing number of ‘baby whisperers’ and ‘sleep experts’, not to mention publishing companies, making a mint out of criticising the method, while thousands of sleep deprived and desperate parents try to wade through the conflicting advice. On the one hand, controlled crying has been shown in a number of well designed controlled studies to significantly improve both infant sleep and maternal mental health. On the other hand, parents are being told that; controlled crying is ‘detrimental to children and can have serious long-term effects’ (Anni Gethin, health social scientist and Beth Macgregor, psychologist, authors of Helping Your Baby To Sleep), that controlled crying ‘is not an evidence-based practice’ and that such ‘rigid regimes can also be associated with infant depression’ (Pinky McKay, International Board Certified Lactation Consultant, and author of Sleeping like a baby, Parenting by Heart, 100 Ways to Calm the Crying, and Toddler Tactics). The difficulty in this debate, is that the scientific evidence is very one sided and actually in favour of controlled crying. No study to date has shown anything but positive outcomes for infants and parents. However, as opponents of the technique are quick to point out, no evidence of harm is very different to evidence of no harm. The opposing camp base their argument on attachment theory and recent research into our body’s stress management system the- hypothalamic-pituitary-adrenal (HPA) axis. Attachment theory would suggest that leaving an infant to cry and not attending to their needs, teaches the infant that their parent cannot be relied upon. The result of this is said to be insecure attachment between parent and child and a state of learned helplessness for the infant. Recent research into the HPA axis has shown that brain is flooded with cortisol when under stress and that chronic stress can permanently affect the brains ability to regulate cortisol re-uptake. Here is the vital question in this debate - Is three or four nights of controlled crying, in the context of a loving home, enough to damage the development of attachment and does it amount to the kind of trauma that has been shown to affect the functioning of the HPA axis? Opponents of the technique have not been able to answer this question and as yet have no scientific evidence to back their theories of irreparable damage. Ironically, in order to provide this evidence they would have to do the very thing they are so passionately opposed to- run a randomised controlled trial of controlled crying. So, in the midst of the controlled crying debate is a rather interesting ethical debate.

Two ‘new’ phrases have entered the lexicon of mental health in recent years – “Recovery Orientation/Based Practice” and “Lived Experience”.  What does this rhetoric really mean and are the terms useful?

The concept of recovery has recently been ‘discovered’ and used to guide service delivery and mental health policy direction.  However it is used inconsistently, and carries with it a number of potential pitfalls.  There is no consistent definition of ‘recovery’ as it is said to have a personal meaning to each individual.  It is not synonymous with ‘cure’.  What it implies is developing greater self efficacy and the pursuit of personal goals and functional capacity, despite ongoing symptoms.  Lived experience is part of this, and the person with mental health problems is the ‘expert’ by virtue of their ‘lived experience’.

Recovery in terms of hope, autonomy and personal growth is very individual and much harder to ‘measure’ than formal assessment procedures.  Control of the recovery process sits with the individual rather than the service or service provider and hence runs the risk of leaving people to their own devices, with consequent neglect under the guise of ‘recovery’.  There is also incongruity between the recovery approach and the use of coercion for those whose illness puts themselves and/or others at significant risk.

The recovery approach could also become a modern day anti psychiatry movement, with the focus on individual recovery and self determination leading to failure to access mental health services.  This leads to another potential problem – where the individual is responsible for their own recovery (a process), and to not ‘recover’ (an outcome) is a great disappointment and perpetuates the sense of personal failure.  Another significant risk is that the concept of recovery may lead to a focus on the personal and the narrative, with exclusion of the systemic, which this may limit the extent of recovery.

It is a grave error to assume that there are two mutually exclusive groups, those with ‘learned experience’ and those with ‘lived experience’.  Many who are professionals in the field of mental health care, have BOTH lived experience and learned experience, though usually do not declare the former.  It may however be used to powerfully influence their work and produce deep understanding and empathy. 

Certainly, hopes, dreams, goals and autonomy are crucial to all of us, but the catch cry of ‘Recovery’ has the potential to do more harm than good.  The exclusive focus on ‘Lived Experience’ has the potential to increase marginalization and stigma, and could be the antithesis of ‘recovery’ - with a focus on difference rather than on universal issues of life.

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How are the processes of intimacy and differentiation, and the exchanges of symmetrical and complimentary communication of a couple relationship different in the gay and lesbian relationship?  And if there is no difference in these aspects of the gay and lesbian couple relationship, then how is it that the external world comes to influence them, such that a therapist must be aware and sensitive to these influences and how they are reflected in the problems presented by gay and lesbian couple?

In asking these questions, Bepko and Johnson (2000) looked at gay and lesbian couples seeking couple therapy and suggest the problems can be classified as being either internal and/or external to the relationship.  These authors propose that cultural and gender biases come to be reflected in both the internal and the external (contextual) problems experience by gay and lesbian couples.

The lesbian/gay couple relationship begins within a context of differentiation, where a person “comes out” to both themselves and another.  Differentiation then becomes a major defining aspect of the individual and the couple relationship, difference in a culture which seeks sameness.  This defining of self as separate from significant others in acted out in a relationship with another that seeks closeness and intimacy.  The dilemma of maintaining separateness and closeness is a stress in the gay/lesbian relationship – great stress/trauma in all relationships deepens already present fractures between the couple.

The social and familial support all couple relationships receive can have a determining factor in how well couples are able to negotiate differences within the relationship.  Having a social world allows for comparison so one can begin to decide what it is they want in a relationship.  A world that highlights difference and infer pathologies, a world that compares and critiques difference, places the lesbian/gay relationship in a state of constant self critique and judgment. 

For the therapist many problems that lesbian/gay couples present with may appear to be similar to those for heterosexual couples, of handling conflict around attachment, closeness and distance, sexuality, power, and differentiation.  Standard tools of family therapy can be used in working with the gay/lesbian couple, such as family of origin work.  A therapists’ understanding and sensitivity to the unique dilemmas experienced by the gay/lesbian couple, how the cultural predispositions bring about a struggle in the maintenance of a gay/lesbian relationship

In preparing for Maurizio Andolfi’s visit to Adelaide in late March, I was fascinated to encounter his view of the recent fate of family therapy.  The very last paragraph of his paper, “A 35 Year Long Personal - Professional Journey”, a work in preparation for possible publication in the Australian and New Zealand Journal of Family Therapy, is entitled “Why Family Therapy Lost its Mission in Social Community Realities?” In the 70’s and 80’s he contends, family therapy developed as a search for “concrete resources and answers in social contexts” which were directly connected to “people’s problems and realities”. For Andolfi, this is not an abstraction for in the early 1970’s as a resident in New York City and Fellow in Social and Community Psychiatry at the Albert Einstein College of Medicine, he worked in the South Bronx with highly disadvantaged families from diverse ethnic groups. This experience was reinforced by his work in South Philadelphia with Salvador Minuchin and Jay Haley. He goes on to suggest that the appropriation of family therapy by tertiary institutions and mental health agencies cost its “marginal perspective” and delivered a place in the mainstream. It has also negated “the pioneering spirit and capacity to speak out against the psychiatric establishment and the institutional bureaucracy”. These changes are reinforced by what he perceives to be an “increased individualism” and resultant consumerism of the last decades. These changes have impacted on therapy which has adapted its interventions from “social and community tools” to “became mostly a service for individual wealthy and lonely clients” and less accessible and used by families.

What also flows from these changes is “an increase in conformist ideas and language” and the development of theories and models “where real people are missing”. Its time, he suggests, to return to “simple, concrete language in order to embrace everyone instead of using complex and abstract concepts with very impressive labels”.

How could anyone disagree, but do we really want to open up the gates, to back away from our increasing passion for accreditation, specialized vocabularies and sanitized practice? You never know who might want to join!

Still going strong after 35 years must be an achievement in any occupation but to be ‘alive and kicking’ as a therapist is surely impressive. Maurizio Andolfi, Full Professor in the Department of Psychology at the University of Rome who trained as a child psychiatrist in Rome and at the Ackerman Family Institute and Philadelphia Child Guidance Clinic in America, can make just such a claim. And you just have to ask “How does he do it?”The answer may lie in his recent paper, prepared for possible publication in the Australian and New Zealand Journal of Family Therapy, “A 35 Year Long Personal - Professional Journey”. In this he elucidates his intergenerational approach to marital therapy with its emphasis on actively including both family of origin, parents and siblings, and children in the presence of each spouse. He regards the generations on either side of the troubled couple as a valuable resource, the previous generation available to help discover new relational pathways and children to ‘enhance information gathering, creativity, flexibility and playfulness”.