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

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.

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