News of the discovery of a young woman abducted off the streets as an eleven year old by a stranger, repeatedly abused and kept prisoner for 18 years has made daily print and television news for the past fortnight. Yet another headline about violence closer to home has passed almost unnoticed. On 1^st September 2009 the Adelaide Advertiser displayed the headline ‘Mum Murder, Domestic Killings Hit Alarming Levels’. The paper reported on the violent deaths of eight South Australian mothers over the past eight months and the call for ‘an official state review into domestic violence related killings’. The Domestic Violence Crisis Service Executive Officer, Gilian Cordel is reported as saying that ‘I don’t think the general public realizes how many women are murdered by their partners’. The response to the article has been minimal producing two letter to the editor and minimal additional coverage. Meanwhile, every day we are regaled with further detail of the investigation of the abductor of Jaycee Dugard.
Why is this so and what does it mean for those of us whose daily work involve those subjected to and perpetrating violence? Perhaps the story of Jaycee is, given its horror, paradoxically ‘easier’. It speaks to every parents’ fear of the unknown madman who randomly selects a child who is then spirited away. The story reads like an episode from a television crime show which ends with the captor’s release. There is no excuse, there is a villain and an innocent victim and the villain will be tried and punished. It can never happen to people we know, people like ‘Us’.
The domestic violence headline is different. This speaks of the murder of women in our community, women who we see in the supermarket with a black eye, whose children play with our children and whose husbands come to dinner. The violence, if it is seen is explained away as a single, random episode or the fault of the recipient. If the woman speaks out to friends she will often experience a pulling away as others feel uncomfortable knowing the secret, are unable to relate to the abuser and would rather not know. More disturbingly the damage is being done by one who should be most able to be trusted who has promised to love and to cherish through sickness and health and who shares a bed. We look into their lives and in many respects they look just like ours. No wonder the article does not precipitate an out flowing of interest. It is received just as the problem is in real life. With silence.
 
Workshop presented by Malcolm Robinson  & Marten Johns
‘Family Violence across the Lifespan: A Trans-generational Perspective’ (click to get more information and register)
 
For all other workshops and events go to http://seminars.bowerplace.com.au

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
          

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

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

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

Reviewing the literature on working with re-married, step or blended families makes for disturbing reading. Most work focuses on the complexity of such arrangements, the loss which inevitably underpins them and the grief and resentment which characterizes the experience of children unwittingly thrown into them. To discover an article which not only proposed a relatively simple way of thinking about these situations and suggestions for therapeutic change was therefore a relief.
Patricia Papernow (1987) proposes the concept of middle ground, “an area of shared experience, shared values and easy co-operative functioning, created over time.” A re-coupled family begins as a collection of already established “mini-families”, each with a different culture, history and rhythm of easily completed interactive cycles. The thickest middle ground exists between parents and their children who share memories, patterns of conflict, play and mutual nourishment which may extend into the wider family system.  While in first time families the couple relationship may be the easiest place to retreat for comfort, understanding and problem-solving, in the re-married family the easier understanding may reside between parents and their children.
Working to thicken the middle ground between the new couple is one way to conceptualize the task of therapy. Seeing the adults alone and inviting in other immediate and extended family member is a way to begin the process by giving them an opportunity to relate without the competition and demands of children. An early step is to lower anxiety which has been precipitated by the awareness of painful differences which cannot be explored due to silence out of fear of conflict or escalating out of control disputes. A therapeutic conversation can allow each person to speak and hear of the very different experience of being in the family. Providing normalizing information, empathizing and supporting can all reduce anxiety.
The act of ‘thickening the middle ground’ is achieved by prescription of shared family rituals, invention of a sense of shared history, planning and negotiating major family gatherings and the establishment of sanctuary time for the couple away from children. Learning to satisfactorily complete a cycle of problem definition, attention to each person’s experience and the achievement of a mutually satisfactory resolution is also crucial. The authors conclude with a positive note “Those who succeed in bridging the chasm exude a sense of vitality and mastery which is rare in first time marriages.”
It’s the first bit of good press I’ve encountered for the beleaguered step-family!
Papernow, P. (1987) “Thickening the “Middle Ground”: Dilemmas and Vulnerabilities of Re-married Couples” Psychotherapy 24, 3S pp630- 639

The Fate of Step Families

Q. What do Cinderella, Hansel and Gretel and Snow White have in common?

A. They all had perfect mothers, ugly step-mothers and pathetic fathers.