Bower Place News

Beyond Baxter Seminar

Your (optional) podcast author email address (Malcolm Robinson) — Wed, 31 May 2006 21:10:00 +0930

Beyond Baxter - Thrown Overboard
Mental health dilemmas & clinical practice with community detainees and former detainees

Presenters: Dr Lynette Rose and Malcolm Robinson

When: 5:00 pm - 6:30 pm Friday 16 June 2006
Where: Bower Place, Level 2, 55 Gawler Place Adelaide, South Australia
How Much: Free + drinks and nibbles
Information: For more information or if you wish to attend the Beyond Baxter Seminar please contact Bower Place
Telephone (08) 82216066
Facsimile (08) 82216061
E-mail malcolm@bowerplace.com.au

Practitioners Workshop Friday 9 June 3:00 - 5:00 pm "Adolescent Self Harm" presented by Catherine Sanders & Nicole Best Practitioners Seminar Friday 16 June 5:00 pm "Beyond Baxter-Thrown Overboard: Mental Health Dilemmas & Clinical Practice with Community Detainees and Former Detainees" Presented by Dr Lynette Rose & Malcolm Robinson Consumers & Clients Conference Saturday 17 June "Marriage & Relationships" Salvation Army City Church, Adelaide SA For more information contact info@bowerplace.com.au

Marriage & Relationships Conference

Your (optional) podcast author email address (Malcolm Robinson) — Tue, 30 May 2006 22:16:00 +0930

The Salvation Army, Adelaide City Church presents

Marriage & Relationships Conference

With Malcolm Robinson

A conference for individuals, couples, prospective couples, people in a relationship, out of a relationship, wanting a relationship, entering a relationship, ordinary citizens, consumers, clients, members of corps & congregations. You do not need to be in a couple relationship to attend this conference.

This conference will look at how to communicate & how to avoid communicating. How to manage and live with similarity, difference & conflict. The seasons of a relationship. Disputes, fairness, love, justice, forgiveness, success, disappointment, kindness, failure, romance, reality, coping with the highs & lows of life in a relationship & the role the Church may play

Saturday 17 June 10:30 am - 3:00 pm

Sunday 18 June 5:30 pm - 7:30 pm

277 Pirie Street Adelaide South Australia

$40 per couple

Free Parking & Childcare Available

$25 per individual

Contact

Andrew Short

E: andrew.short@aus.salvationarmy.org

T: (08) 8223 7776

F: (08) 8232 6043

Postal Address

Marriage & Relationships Conference

Adelaide City Church

277 Pirie Street

Adelaide South Australia 5000

Seeing is Believing

Your (optional) podcast author email address (Malcolm Robinson) — Mon, 29 May 2006 21:58:00 +0930

As clinicians we have all had the experience of working with challenging children and their families, whose difficulties have not responded to therapy.

Clinicians at the Southern Child and Adolescent Mental Health Service in Adelaide, South Australia and the Family Development Centre in Wellington, New Zealand have devised a process entitled Parent and Child Therapy. This is an attachment-based intervention using the notion of 'supported looking'. 'Supported looking' between carer and child is designed to ‘reduce distorted perception and provide a basis for clinical intervention with parents and older children’.

Parent and Child Therapy is a four-stage process.

This begins with history taking which aims to ‘work with the narrative aspect of the internal working model of both the parent and the child in parallel’.

This is followed by a preparation of both parties to meet ‘as if for the first time’.

Phase three, an experiential task for mother and child involves the mother viewing the child from 10 to 20 minutes through a one-way screen while supported by the therapist to ‘watch, wait and wonder’.

Once the parent can demonstrate empathy for the child in the relationship it is time for the fourth stage of ‘Looking After’. Now the mother joins the child and therapist in the room and is supported to build the relationship anew through child directed play.
The article concludes with a case study of four-year Josh and his mother Sue who successfully renegotiated their understanding of, and connection to, each other in a manner that has been successfully maintained for eight years ‘ despite difficult life events’.

This is joyful work and may just reconnect therapists to their own heart.

Chambers, H, Amos, J, Allison, S, Roeger, L. “Parent and Child Therapy: Attachment Based Intervention for Children with Challenging Problems” ANZJFT Vol 27 No 2 pp 68-74

Getting Attached in the Right Places

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 28 May 2006 23:10:00 +0930

Intuitively, it has always made sense that family therapists and attachment theorists would make good bedfellows. Attachment is, by its very nature, about relationship, and about relationship between intimates, the baby, the child, and their primary carer.
Anyone who has seen James Robertson’s film “A Two Year Old Goes to Hospital,” which details the process of separation of a child from her family, will appreciate the agony of the child as she moves from active protest to despair akin to depression. Such a dramatic demonstration makes it hard to maintain that attachment is not one of the central processes in the life of a family.
The most recent edition of the Australian and New Zealand Journal of Family Therapy (ANZJFT), Volume 27, 2 has embraced this as its theme. This is the first of two editions with guest editor Dr Steve Allison. The second edition will appear in 2007.
In an interview, Professor Graham Martin details the centrality of attachment theory to his work with children in hospital, youth suicide and therapeutic work with families. This is followed by a set of excellent articles which apply attachment theory to clinical practice.
In 2002 Family Process published a special edition entitled “Attachment and Family Systems”. The authors in this edition addressed theoretical and clinical issues and broadened their perspective to include attachment and the couple relationship, adolescence, culture and community.
Let us not forget that, just as we can draw idea like attachment to us, we can also take it out into the world. Dr Ann Sved-Williams, a pioneer teacher and practitioner of family therapy in Australia, established infant mental health training in Adelaide at Helen Mayo House, a facility within the Mental Health Services. Her 2003 ANZJFT paper, which articulates the intersection of infant mental health and family therapy, not surprisingly includes a section on attachment.

Alcibiades & Pericles

Your (optional) podcast author email address (Malcolm Robinson) — Fri, 26 May 2006 06:37:00 +0930

5th century B.C
Alcibiades debated his uncle, the Greek leader Pericles.
Pericles: "When I was your age, Alcibiades, I talked just the way you are now talking."
Alcibiades: "If only I had known you, Pericles, when you were at your best."

Voices from the Storm: Emergency Docs Share Their Stories

Your (optional) podcast author email address (Malcolm Robinson) — Wed, 24 May 2006 22:24:00 +0930

H Vankawala and R Charles

These are excerpts from an e-mail post Hurricane Katrina which was published in Clinical Psychiatry News, Australian Edition, Nov-Dec 2005. More than the images on television, they indicate the extent of the human toll. It is amazing to think of medicine practiced at this most basic level in a developed nation in 2005.

New Orleans Airport, Sept 6th 2005

I am a member of the Texas-4 Disaster Medical Assistance Team (DMAT)… For the past 8 days, I have been living and working at the New Orleans airport, delivering medical care to the Hurricane Katrina survivors.
Our little civilian team, along with a couple of other DMAT teams, set up and ran the biggest evacuation this country has ever seen.
Our busiest day, we offloaded just under 15,000 patients by air and ground. At that time we had about 30 medical providers and 100 ancillary staff. All we could do was provide the barest amount of comfort care.
We watched many, many people die. We practiced medical triage at its most basic, black tagging the sickest people and culling them from the masses so they could die in a separate area.
We were so short on wheelchairs and litters that we had to stack people in airport chairs and lay them on the floor. They remained there for hours, too tired to be frightened, too weak to care about their urine and stool soaked clothing, too desperate to even ask what was going to happen next.
We did everything from delivering babies to simply providing morphine and a blanket to septic and critical patients and allowing them to die. Many of the sickest simply died while here at the airport; many have been stressed beyond measure and will die shortly.
You will never think of America the same way.
Other articles in the same publication talk of the cascade of disasters magnifying trauma – hurricane, flooding, relief efforts, and forced relocation/displacement. Fragmentation, with people being sent everywhere, meant separation from family and friends, and minimal social support, exacerbating the risk of psychological problems.
Articles stressed the importance of attending to basic practical physical issues of injury, food and water, clothing and shelter, and assistance to locate and communicate with family and friends before more complex psychosocial and psychological needs can be addressed in disaster mental health.

Australian & New Zealand Journal of Family Therapy Google Group

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 21 May 2006 21:17:00 +0930

Friday June 16th is the starting date for the next, Multi JFT Forum, an e-mail based discussion run jointly by Family Process (USA), Journal of Family Therapy/Association of Family Therapy (UK) and the ANZJFT.
Ben Hansen and Paul Rhodes, the Moderating Team, select a paper from the ANZJFT which forms the basis of the discussion. This time they have chosen Carol Boland’s (2006) paper, ‘Functional Families: Functional Teams’, which appeared in Volume 27, 1 and was reviewed on this site.
In order to join the discussion send an empty email to
MultiJFTForum-subscribe@googlegroups.com.

5th Phase for Family Intervention with Schizophrenia?

Your (optional) podcast author email address (Malcolm Robinson) — Sat, 20 May 2006 18:50:00 +0930

Gianfranco Cecchin the mercurial gnome to Luigi Boscollo’s solid bear, died tragically and unexpectedly in a car accident in 2004. As one of the Milan team, he and his psychiatrist collaborators, including team leader Mara Selvini Palazzoli and Guiliana Prata returned to the work of Gregory Bateson as the guiding principles for working with families. Out of their collaboration came Paradox and Counter-Paradox, the text that made them famous for their work with patients with a diagnosis of schizophrenia and established them as the founders of the Systemic School of Family Therapy.
Paolo Bertrando, Director, Episteme Centre in Italy published a paper reviewing the evolution of family interventions for schizophrenia, as a tribute to his deceased colleague. In it he proposes four distinct phases in interventions for schizophrenia. The first from 1955-1965, Conjoint Family Therapy aimed at altering dysfunctional family communication patterns; a second from 1965-1975 termed Anti-Psychiatry was a philosophical position rather than a treatment approach which suggested that schizophrenia was a response to the malaise of western society. The third, Milan Systemic therapy (1975-1985) located symptoms in the relationship patterns within and beyond the family with a particular emphasis upon meaning. Finally the fourth phase, Psycho-education, (1985-2002) aimed to support and educate family members in relation to the illness and to establish co-operation around treatment issues such as medication and rehabilitation. Bertrando proposes a fifth phase where psychoeducational practices are ’merged with other therapeutic modalities’. He suggests there is a wealth of ‘ideas, visions and techniques, belonging to different traditions that may be integrated with the practice of psychoeducation’ including attention to relational patterns and alliances, tri-generational issues, meaning of symptoms and the re-creating of life stories.
It will be interesting to see wether the dramatic swings in orientation and philosophy that have characterised the history of the treatment of schizophrenia will so readily settle into this collaborative and respectful position.

Bertrando,P (2006) ‘The Evolution of Family Interventions for Schizophrenia’ Journal of Family Therapy Volume 28,1 p 4-22

CBT and Psychosis

Your (optional) podcast author email address (Malcolm Robinson) — Thu, 18 May 2006 17:17:00 +0930

Initial teaching was that delusions were fixed beliefs, and therefore would not respond to reasoning. CBT challenged this when it was proven effective in psychosis, applied to the delusions and dysfunctional thinking to reduce psychosis, improve insight and improve compliance with medication.
Two issues arise. One is that CBT is now often used in a generic manner, by people poorly trained and with limited experience in CBT for psychosis, diluting its effectiveness. The second and perhaps larger issue is that there has been a failure to consider the role of emotion in non affective psychotic illness.
A recent article in the British Journal of Psychiatry (Birchwood and Trower 2006) highlights affective symptoms as part of the prodrome of psychotic illness, and that distress and behavioural disturbance may well result from the appraisal of psychotic experiences, and not just as a direct effect of psychosis..
In many areas of psychiatry, therapies have preceded theory – theories have been derived as a secondary process. CBT for psychosis appears no different. Theories need to be generated and tested, and CBT used in a much more specific and targeted manner, in areas other than reduction of delusions and better insight. These may include reduction of distress, depression and behavioural problems associated with the experience of psychosis, the emotional response to and therefore the action when early warning signs are recognised (these are often non specific non psychotic symptoms), dealing with anxiety and depression in psychosis, improving evaluation of and resilience to stress (which is associated with increased risk of relapse), improving self esteem and social confidence, and therefore improving the level of function across a range of areas (even when symptoms are ongoing).

British Journal of Psychiatry The future of CBT for psychosis: not a quasi neuroleptic Max Birchwood and Peter Trower 2006 188: 107-108

Managing Complex Matters & Systemic Co-Morbidity

Your (optional) podcast author email address (Malcolm Robinson) — Tue, 16 May 2006 23:10:00 +0930

When it's all too confusing: Managing complex, co-morbid individual, couple and family 'mental health' difficulties in a complicated systems context
A workshop for practitioners & students
Co-morbidity is ordinarily defined in terms of the concurrent presence of more than one major ‘mental health’ disorder in an individual. Major depression often presents as a co-morbid disorder & the rate with personality disorder may be as high as 60%. Physiological & psychological co-morbidity is also high with substance abuse. The symptoms that many couple & family systems carry, suggests that they too are systemically co-morbid. Such cases are often a gathering point for a bevy of family & professional systems leaving the practitioner feeling helpless & confused. This workshop sets out an integrated systemic approach to the assessment & intervention of complex co-morbid cases & will address the expansive complex systems context of these clients. Attention will be paid to the confusing & contradictory information & solutions in place in such cases & aims to put the practitioner in charge of the process.

Workshop 1: Bower Place Advanced Practice Workshop Series
Presented by Malcolm Robinson

Friday 19 May 3:00 pm to 6:00 pm
Bower Place, Level 2, 55 Gawler Place Adelaide SA 5000
Fee: $55 (includes GST)

Information
E malcolm@bowerplace.com.au
T +61 8 82216066
F +61 8 82216061
PD points can apply

Beaconsfield Goldmine Disaster: It’s Just Like Life

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 14 May 2006 20:21:00 +0930

As a nation we followed with anxiety and distress the disaster in the Beaconsfield Goldmine, one man dead and the saga of two men trapped one-kilometer underground, culminating last week in their triumphant rescue. As the days ground on, we became increasingly familiar with the media reaching for superlatives as they extracted every last drop of ‘news’ from this gruelling crisis. This reached its height on the day of the rescue. More disturbing than the hype was their apparent incredulity that a ‘miracle’, the rescue of the trapped men, and the funeral of their workmate, could possibly occur on the same day. It was as if we had come to believe that life comes in only two forms: success, joy and celebration, or failure, death and mourning. Entertainment, a good ending or a tragic ending, seems to have become the norm, and the apparent contradiction of rescue and burial seemed inconceivable. It lead me to wonder at what point we had lost sight of the words of the Christian funeral service said at the graveside as the body is lowered into the grave “In the midst of life we are in death”. Life and death are not neatly compartmentalised events that never coexist. In the work we do we are often brought face to face with the contradiction of the two intersecting. It is not always as tangible death. We witness one person’s liberation condemn another to the grief of loss of that person and the intimate arrangement of which they were once an integral part. In our work we may support a young person to emotionally leave home and leave parents who are faced with the collapse of the old family unit and, perhaps, even the dissolution of their relationship. No doubt, at some point the joy and relief of the trapped miners and their families will be tinged by the bitter guilt of the survivor and the grief of the bereaved touched by the joy of the spared. As in all things both are inextricably intertwined.

Adolescent Cutting - How to Explain, How to Respond

Your (optional) podcast author email address (Malcolm Robinson) — Wed, 10 May 2006 06:32:00 +0930

Bower Place, Friday 12 May 2006 12:30 pm to 1:30 pm

Nicole Best & Catherine Sanders will repeat the “Adolescent Cutting - How to Explain, How to Respond” lunchtime seminar

Review of the April 6 Seminar

Practitioners at Bower Place have noticed a curious increase in clients with this symptom and supposed that our colleagues may be experiencing the same thing. We were ill prepared for the enormous response we received. The seminar was fully booked within 48 hours and a second seminar booked 24 hours later. Clearly adolescents who self harm by cutting themselves are exercising the thoughts of many practitioners. Nicole & Catherine presented a segment of videotape of a young woman speaking about her experience of cutting & then a review of the literature, which attempts to explain this behaviour, followed by guidelines for clinical ‘what to do’ management of this condition. Whilst seminar participants were clearly interested in the literature & explanations about this symptom, the greatest enthusiasm was in the ‘what do we do?’ discussion which continued over the lunch. Perhaps the strongest focus was on the seemingly ’contagious’ nature of ‘adolescent cutting’. This was particularly expressed by those working in schools, where a ‘group’ may form around a young person who is ‘cutting’ and it may then become a behaviour exhibited by all members of that group. These are interesting perceptions in light of the literature, which refers of a distinction made by young people; between those who self harm for ‘genuine’ reasons and those who ‘attention-seek’. It appears that the ‘genuine’ cutters express contempt for the ‘attention-seekers’, who put on a display of their wounds for others to see. In order to be seen as ‘genuine’ a certain level of damage must be inflicted but it must be kept a secret. Young people may view the ‘attention seeker’ as being rather pathetic & perhaps even competitive with the ‘real’ self-harming person. This then adds another layer of complexity to clinical treatment of adolescent self harm and ‘cutting’ in particular. ‘Cutting’ is a serious symptom that appears to be expressing unmanageable ‘pain’ in a person’s life, yet if it is shown & spoken about that person is then defined as ‘attention seeking’ and not really suffering. That young person is also at risk of rejection by his or her peers at a time when a large part of the adolescent developmental struggle is about acceptance. This distinction between the ‘genuine’ and ‘attention seeking’ cutters appears to be particularly unhelpful and one that those who work with groups of young people are also invited to adopt. The person who ‘self harms’ is communicating with the world around them in the most dramatic way imaginable, that they are suffering some unspeakable form of distress for which they cannot find words. To draw a distinction that suggests that those who overtly draw attention to their actions are less ‘genuine’ and less deserving of help than those whose actions are hidden & secret seems unkind and unhelpful. However, it is interesting to wonder whether the issues with which each group struggles are as different as their style of presentation or in fact more similar.

The next seminar

Friday 16 June 2006 at 5:00 pm

"Beyond Baxter - Thrown Overboard: Mental Health Dilemmas & Clinical Practice with Community Detainees & Former Detainees."

Presented by Dr Lynette Rose & Malcolm Robinson

Contact malcolm@bowerplace.com.au for more information

How Do You Solve This One?

Your (optional) podcast author email address (Malcolm Robinson) — Wed, 10 May 2006 06:24:00 +0930

The authors of the British “Report of the National Enquiry into Self- Harm among Young People” interviewed adolescents who had engaged in self–harming behaviours as a way of exploring treatment options. The majority of the respondents believed that they could manage their situation alone and did not require specialist services. Further, they believed that such resources would not understand or respond appropriately. This finding reflects the paradoxical nature of the young person’s dilemma, which is clearly articulated by Crouch and Wright in their 2004 paper on a qualitative study of deliberate self-harm in an adolescent unit. They report that ‘participants expressed and acknowledged ambivalent feelings about themselves and contradictory expectations about what they needed from others’, they expressed a struggle between needing to be helped and feeling this was unnecessary, between independence and dependence, to disclose and to be private, a fear of rejection and a desire to be understood. While this is not uncommon for any adolescent client it constitutes an additional challenge for the development of appropriate, acceptable services to a group who so desperately need an effective response.

Truth Hurts: Report of the National Enquiry into Self- Harm among Young People; 2005; Mental Health Foundation, UK

Crouch, W & Wright, J "Deliberate Self Harm at an Adolescent Unit: A qualitative Investigation" Clinical Child Psychology & Psychiatry Vol 9 No 2 2004 pp 185 -204

A Comprehensive Service

Your (optional) podcast author email address (Malcolm Robinson) — Tue, 9 May 2006 22:27:00 +0930

The issue of appropriate intervention for young people who self-harm is of concern for all those who work with this population. A service developed in Glasgow provides an assessment & intervention service for 12-17 year olds. The service is staffed by a nursing team. It is a 24-hours/day 7-days/per week, service to a District General Hospital and Accident & Emergency Departments in other hospitals. The service accepts referrals from a Child & Adolescent Mental Health Service where the primary presenting problem is deliberate self-harm. The focus is on the assessment of the young person & their family with an initial goal of crisis management. The young person is given a crisis card with contact numbers for the nurse therapist & other emergency services. Follow up is in the home including a psychosocial risk assessment & interviews with both the presenting person & their parents. Between 4 & 10 therapy sessions may then occur, focussing upon solutions to the difficulties the young person & their family are experiencing. Therapy, using cognitive behavioural techniques may address adolescent issues, problem resolution & communication difficulties. At the conclusion of therapy the young person is offered 3 appointments per year in order to maintain a review of their situation. They can recontact in the event of a crisis. It will be interesting to see outcome studies from this approach.

Truth Hurts: Report of the National Inquiry into Self Harm among Young People; 2005; Mental Health Foundation (UK)

There is a Research Opportunity Here

Your (optional) podcast author email address (Malcolm Robinson) — Tue, 9 May 2006 22:19:00 +0930

For a symptom as prevalent as adolescent self-harm there is a remarkable absence of good research into effective intervention strategies. A range of definitions as to what constitutes self-harm bedevils the literature. There is a reliance upon subjects admitted to a hospital or psychiatric unit and a reliance upon self-report measures. In addition authors emphasise different perspectives, with some responding to the behaviour as indicating a poor capacity to regulate strong emotion, whilst others look more to underlying past and present life and relationship experiences. Tantum and Whittaker view self-harm behaviour as an ‘addictive’ behaviour. Not surprisingly there is a lack of consensus about the most appropriate and effective treatment strategies. One of the few formal research studies is by Linehan et al (1991) who conducted a randomised clinical trial to evaluate the effectiveness of a cognitive-behaviour therapy, dialectic behaviour therapy, over a one-year period, with chronically parasuicidal women who met the criteria for a diagnosis of borderline personality disorder. Their results suggest that those receiving this treatment showed fewer and less medically severe incidents of self-harm at most assessment points. However it appeared to have no effect on depression, hopelessness, suicidal ideation or reason for living. It is hard to know how meaningful this is to young people who self harm. The study fails to distinguish self–harm from suicide and involves an adult psychiatric population. Given the apparent importance of family relationships in the aetiology and maintenance of the symptom it would be interesting to research the effectiveness of family therapy approaches. Now that’s a challenging research proposal!

Workshop: Complex, Co-morbid 'Mental Health' Difficulties

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 7 May 2006 22:32:00 +0930

When it's all too confusing: Managing complex, co-morbid individual, couple and family 'mental health' difficulties in a complicated systems context

A workshop for practitioners & students

Co-morbidity is ordinarily defined in terms of the concurrent presence of more than one major ‘mental health’ disorder in an individual. Major depression often presents as a co-morbid disorder & the rate with personality disorder may be as high as 60%. Physiological & psychological co-morbidity is also high with substance abuse. The symptoms that many couple & family systems carry, suggests that they too are systemically co-morbid. Such cases are often a gathering point for a bevy of family & professional systems leaving the practitioner feeling helpless & confused. This workshop sets out an integrated systemic approach to the assessment & intervention of complex co-morbid cases & will address the expansive complex systems context of these clients. Attention will be paid to the confusing & contradictory information & solutions in place in such cases & aims to put the practitioner in charge of the process.

Workshop 1 in the Bower Place Advanced Practice Workshop Series

Presented by Malcolm Robinson
Friday 19 May 3:00 pm to 6:00 pm

Bower Place, Level 2, 55 Gawler Place Adelaide SA 5000

Fee: $55 (includes GST)

Information

E malcolm@bowerplace.com.au

T +61 8 82216066

F +61 8 82216061

PD points can apply

Risk Factors and Psychopathology

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 30 Apr 2006 22:25:00 +0930

Abuse and neglect in childhood and insecure attachment are not only associated with deliberate self harm, but also with a range of psychopathology in adulthood, including depression, anxiety, dissociation, borderline and dependent personality disorders. Not everyone who is abused and/or neglected goes on to develop significant psychopathology however - other factors including temperament and resilience, environment and other supports all play a part. Self harm that persists into adulthood is more likely to be associated with significant psychopathology.
A histroy of significant abuse in childhood is almost universal in borderline personality disorder. It is sometimes mistakenly assumed that everyone who self harms must have borderline personality disorder - this is not the case. It is a label that is often used pejoritavely. Mood instability, unstable intense relationships with a very black/white view of people, identity problems, efforts to avoid abandonment, impulsivity, chronic feelings of emptiness and problems with anger also characterise borderline personality problems.

Fatter & Less Fit

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 30 Apr 2006 13:33:00 +0930

Readers of Adelaide’s local newspaper will have encountered a series of articles addressing Australia’s obesity problem & encouraging us to look seriously at our diet & lifestyle. Clearly we are not only fatter as a nation we are significantly less active.
This focus on our sedentary lifestyle and its implications for obesity was taken by Professor Andrew Hills PhD, Co-Director , ATN Centre for Metabolic Fitness ,who conducted a seminar for psychologists, entitled ”Management of Obesity: Overcoming the Inertia” He demonstrated a population wide decline in physical activity which is comprised of a decline in work related activity, a decline in transportation activity, a decline in home activity & an increase in sedentary activity. Interestingly only leisure time physical activity remained level or slightly increasing. He summarised these trends by stating that the increase in life expectancy which we have come to expect may well come to an end with our current young people who may on average ‘live less healthy & possibly even shorter lives than their parents”. For children obesity related health consequences include psycho-social problems, accelerated growth & maturity, dyslipidemia, elevated blood pressure, insulin resistance, orthopedic difficulties and sleep apnea. There is no doubt that in our appearance sensitive world, self-esteem, self concept, body image & body dissatisfaction are affected by weight & size.
Dr Hills recommended a refocussing from weight to fitness. His view is that to focus on a person’s weight per se is to reinforce the psychosocial problems that accompany obesity. Rather we should be encouraging people to set goals around increasing activity & feeling healthier in a way that is not tied to a number on the scales. Leaner is not necessarily lighter and the goal should be an improvement in body composition, with a reduction and maintenance of fat loss not necessarily weight.
This is an important and immediate challenge for the experts in change.

Adolescent Cutting: Risk Factors

Your (optional) podcast author email address (Malcolm Robinson) — Sun, 30 Apr 2006 12:23:00 +0930

Gratz (2003) review of the self-harm literature examined six potential childhood risk factors.
Childhood sexual abuse received the most attention from researchers. The evidence suggests a unique relationship between childhood sexual abuse & self-harm in adulthood, particularly for women. Other predictors include physical abuse, neglect, prolonged separation or loss of a caregiver, quality of attachment to caregiver & individual factors of biological vulnerability, all of which suggest a relationship albeit unsubstantiated. The most compelling findings from these limited studies is that emotional neglect may be a stronger predictor of deliberate self-harm than sexual & physical abuse. This warrants further investigation as there is some evidence both emotional & physical neglect may have serious negative consequences for later ego control, affect expression, & emotion regulation, all of which are implicated as potential risk factors for deliberate self-harming behaviour. Most striking in examining these potential risk factors for self-harm is the overriding sense that the interaction of more than one of the above childhood risk factors may increase the risk for later self-harm behaviour. For example, childhood physical abuse, combined with emotional & psychological abuse, or childhood trauma, neglect & insecure attachment, or childhood sexual abuse & an invalidating family environment together predict a greater likelihood of self-harm behaviour.

Gratz, K. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10(2), 192-205.

Pseudo Science & Serotonin

Your (optional) podcast author email address (Malcolm Robinson) — Wed, 26 Apr 2006 23:11:00 +0930

Just as in clinical trials, it is important not to take on board without question all that one reads. The assertion that there is a chemical basis to self harm, somehow involving endogenous opiods (endorphins) and serotonin, is attractive but simplistic pseudo science, without an adequate evidence base. The issue of questioning the evidence base is clearly illustrated. The comments re serotonin depletion are based on an article in the American Journal of Psychiatry (New, A. et al (2005) Brain Serotonin Transporter Distribution in Subjects with Impulsive Aggressivity. American Journal of Psychiatry,162 (5), 9_5-923) where 10 subjects, average age 35, with significant pathological impulsive aggression (not deliberate self harm) were studied. They had significant co morbidity which included borderline, antisocial, schizotypal, narcissistic, obsessive compulsive, histrionic, dependent and avoidant personality disorders, and suffered from depression, dysthymia, bipolar disorder, generalised anxiety, social phobia, obsessive compulsive disorder, body dysmorphophobia, alcohol dependence and alcohol abuse. Serotinergic depletion could have had many causes, and this is an extremely disturbed and hardly comparable group, not to mention there were only 10 of them!!!

If self cutters had tolerance to endorphins, then you would also expect tolerance to exogenous opiods (eg morphine) – this is not so. If there was a high level of endogenous endorphins circulating, then you would also expect a higher than usual tolerance to pain in general – again this is not the case. SSRI’s increase the level of serotonin at binding sites in the brain, this is a partial explanation of how they work in depression, so if serotonin depletion was a significant contributor to deliberate self harm, you would expect SSRI’s to be an effective treatment - in general they are not (unless there is a significant depressive illness).
Deliberate self harm is a complex behaviour which results from complex developmental and psychosocial factors, and can be associated with clinical depression, anxiety, personality disorders and other psychiatric problems. The mind and the brain are closely entwined, and there may certainly be subtle neurotransmitter changes, but this by no means simple nor proven.

Two Women and a Baby

Your (optional) podcast author email address (Malcolm Robinson) — Mon, 24 Apr 2006 12:01:00 +0930

My route to work each day takes me through the city centre & the end of the Rundle Mall, the central shopping area for Adelaide. Sometimes I get a clear run with every traffic light green and on other days, especially when I’m running late, it seems that my mere presence makes the lights turn red.
One morning when the lights knew I was rushing, I found myself self stationary adjacent to a bus stop at the end of the Mall. To contain my frustration I entertained myself by watching the people waiting at the bus stop. Seated was an austere looking elderly woman dressed in drab beige & brown set against her pallid white skin. Unsmiling, she sat, staring into the middle distance, waiting for her bus. She looked tired. Standing immediately behind her was a tall, striking, young African woman. Her hair was wound up inside a traditional 'turban' & she wore a full length dress that was wild collection of bright patterns & vivid colors. She too stared into the street, her face blank & expressionless. I wondered for a moment about the reception she had received in Australia & what the elderly woman might have to say.
From behind the seat a tiny child wobbled out, his hair dark & curly, his skin shiny & black, his face open & joyful. In his plump little hand he clutched a brown autumn leaf. He approached the older woman & thrust the leaf toward her. Her attention was captured as she looked down & into the face of the child. For one millisecond I feared she would ignore this innocent child’s offering, but her face then opened & softened as she leant toward him to accept his gift. She glanced up and caught me watching them. We both smiled and the lights changed. It didn’t matter anymore that I was late for work.

It’s Not All Psychological

Your (optional) podcast author email address (Malcolm Robinson) — Mon, 24 Apr 2006 09:58:00 +0930

In exploring the issue of self-harm in young people it is easy to forget that this confrontingly physical symptom may be supported by a biological element. A group of neurochemicals known as endogenous opioids, similar to to opium & heroin, are released when a person is frightened & believes they are in danger, particularly when there is bodily injury. These opioids produce a positive feeling of calm, well-being and insensitivity to pain, which allows a person to act self protectively in dangerous situations. Clearly these opioids have positive survival value.
These chemical responses are even more important to understand, as it appears that the body comes to require increasing levels of these substances to produce the same positive effect. Consequently more physical damage must be inflicted for the same outcome. This carries with it an increasingly risk of serious & permanent injury and even death, even though the motivation is not to end a life.

The neurotransmitter, Serotonin, is also important. People subjected to high levels of stress experience Serotonin depletion. The consequence is an increased risk of impulsive actions & a lack of constraint, making it harder to resist the desire to self-harm.

The Issue of Bias

Your (optional) podcast author email address (Malcolm Robinson) — Thu, 20 Apr 2006 13:59:00 +0930

The issue of bias, often subtle, in reports of clinical trials, is well recognised. Unfortunately, there is little funding for research independent of the pharmaceutical industry. I fully support the findings of the paper – but not just in relation to the novel antipsychotics, but in ALL papers related to clinical trials. There are many sources of potential bias in all trials, even those not involving medication.
With specific reference to drug trials, funding should be ‘hands off’, researchers should have editorial control, and researchers should be able to publish all results, even those unfavourable to the company sponsoring the research. They should have control over the nature of statistics used, and how they are used and interpreted. Competing interests of researchers should be declared, including funding for speaking tours and conference attendance. These are just some examples on how to reduce sources of bias and distrust in clinical trials.

The report mentions things such as doses, dose escalation, statistics and selection, but in addition, clinical trials often do not relate to the ‘real world’ – long term often being 6 – 12 weeks, rather than years. Participants are often highly selected - in America they are often paid and are ‘professional’ study participants. All this makes me view clinical trials with considerable caution.
With specific reference to novel antipsychotics, in my experience most are of similar efficacy when used at appropriate doses, different ones suiting different people, and side effects being the main differentiating feature. They have different side effects than the older medications, but none are without significant potential problems.

Why olanzapine beats risperidone, risperidone beats quetiapine, and ...

Your (optional) podcast author email address (Malcolm Robinson) — Mon, 17 Apr 2006 10:39:00 +0930

Why olanzapine beats risperidone, risperidone beats quetiapine, & quetiapine beats olanzapine: an exploratory analysis of head-to-head comparison studies of second-generation antipsychotics.

Heres S, Davis J, Maino K, Jetzinger E, Kissling W, Leucht S. American Journal of Psychiatry 2006 Feb; 163 (2) :185-94

OBJECTIVE

In many parts of the world, second-generation antipsychotics have largely replaced typical antipsychotics as the treatment of choice for schizophrenia. Consequently, trials comparing two drugs of this class--so-called head-to-head studies--are gaining in relevance. The authors reviewed results of head-to-head studies of second-generation antipsychotics funded by pharmaceutical companies to determine if a relationship existed between the sponsor of the trial and the drug favored in the study's overall outcome.

METHOD

The authors identified head-to-head comparison studies of second-generation antipsychotics through a MEDLINE search for the period from 1966 to September 2003 and identified additional head-to-head studies from selected conference proceedings for the period from 1999 to February 2004. The abstracts of all studies fully or partly funded by pharmaceutical companies were modified to mask the names and doses of the drugs used in the trial, and two physicians blinded to the study sponsor reviewed the abstracts and independently rated which drug was favored by the overall outcome measures. Two authors who were not blinded to the study sponsor reviewed the entire report of each study for sources of bias that could have affected the results in favor of the sponsor's drug.
RESULTS

Of the 42 reports identified by the authors, 33 were sponsored by a pharmaceutical company. In 90.0% of the studies, the reported overall outcome was in favor of the sponsor's drug. This pattern resulted in contradictory conclusions across studies when the findings of studies of the same drugs but with different sponsors were compared. Potential sources of bias occurred in the areas of doses and dose escalation, study entry criteria and study populations, statistics and methods, and reporting of results and wording of findings.

CONCLUSIONS

Some sources of bias may limit the validity of head-to-head comparison studies of second-generation antipsychotics. Because most of the sources of bias identified in this review were subtle rather than compelling, the clinical usefulness of future trials may benefit from minor modifications to help avoid bias. The authors make a number of concrete suggestions for ways in which potential sources of bias can be addressed by study initiators, peer reviewers of studies under consideration for publication, and readers of published studies.

Thanks to Ian Johnston, School of Psychology, The University of Sydney, NSW

Self-Cutting Who Does it More & How Often?

Your (optional) podcast author email address (Malcolm Robinson) — Sat, 15 Apr 2006 12:52:00 +0930

It’s been an interesting & confusing process exploring the ‘self-harm’ literature. There is poor agreement across studies about the prevalence of the problem and gender distribution. Tantam & Whittaker (1992) confidently state that among adults “more men than women do it, although more women receive psychological treatment.” Gratz et al (2002), in a study that focused on college students, reported that 38% had deliberately self harmed & that this was not significantly associated with gender. They noted this as discrepent from the other literature which suggests that more women self-harm than men.

The British “Truth Hurts-Report of the National Inquiry into Self-harm among Young People” commissioned in 2004 & released in 2006 advise caution in arriving at conclusions given the wide variations in the research methodology of the papers they reviewed. This Report suggests an incidence of between 1 in 12 & 1 in 15 across the UK. One interesting statistic they quote in relation to hospital treated incidents shows that in the 15 to 19 year age group more girls than boys present, whereas this is reversed for the 20 to 24 year age group.

One can only agree with their conclusion & that of a number of other authors, that there is a “clear and important need for much better data on the prevalence of self- harm in young people.”