BLOG POST ARCHIVES

** Period:      till end July 2012 -- This Page

I warmly encourage contributions from those with different views, different experiences, and thus speaking from different perspectives, to my own, but I do ask for those contributions to be respectful, and even assertive, of the personhood, rights, and dignity of all people equally.  This is a standard I shall endeavour to hold to for myself. I also ask you to hold me to this standard and to let me know if I fail.

This site was set up in honour of those friends (Wayne) and loved ones (Kerry, Mauretta) I have lost who have suffered at the hands of others who were not able to love and care for them as they should. They will not be forgotten and hopefully this site will help ensure that others will not have to struggle alone along the trail from dark times to mastery of one's demons, greater peace, and happier, more successful relationships.

Medscape Psychiatry has announced that the results  of the firld trials for changes in DSM-IV, to be included in DSM-V, to be officially published in 2013, will very soon be  announced at this year's conference of the American Psychiatric Association.  This is important for followers of resarch and treatment for survivors ofchildhood abuse and trauma, as it should foretell the future of the inclusion of Developmental Trauma Disorder -- [LINK] in the new version of ths Diagnostic Manual -- (see the publications page at the Trauma Center of the Justice Resource Institute for the seminal articles)-- one of THE core issues in our field. Also at the conference will be the results of field trials for changes in the criteria for Posttraumatic Stress Disorder, and thus likely to affect the treatment of adult sufferers of childhood abuse and neglect --  will you still be a "Personality Disorder" after this year's conference? Will it change how you can hope to be treated?  Stay tuned, subscribe to this blog, and find out.  As soon as I find out, I'll post it here.

One size does NOT fit all for trauma counselling
Not surprisingly, research has shown what many of us have felt for a long time -- our early traumatic relationships badly affect our ability to have a variety of types of relationships, including those with our "formal" caregivers -- our doctors, psychiatrists and counsellors. The nature of relationship is vitally important to the success of the treatment and counselling we receive -- fully equal partnership and consensus over treatment goals and process are vitally important. Even more recent research supports this -- Johnson, 2012 [LINK]

In the Feeny et al (2012) study, patients with posttraumatic stress disorder (PTSD)  and comorbidities of major depressive disorder (MDD)  or childhood sexual abuse (CSA)  were found to be particularly sensitive to not getting their treatment of choice, with this effect predictive of poorer treatment outcome. "What seems to be driving impaired recovery is not getting the treatment you want, and in certain subgroups you see a particularly robust impact of this discrepancy," principal investigator Norah Feeny, PhD, director of the PTSD Treatment and Research Program, Case Western Reserve University, in Cleveland, Ohio, told delegates attending the Anxiety Disorders Association of America (ADAA) 32nd Annual Conference. "A one-size-fits-all approach is not going to continue to work for the treatment of PTSD." -- [LINK]

Readers may also be interested in an early study on factors affecting client-therapist alliance early in treatment for PTSD, including clients' experience of childhood trauma -- Keller, Zoellner & Feeny (2010) -- [LINK]

This list was started to represent the interests of those who were abused as children, regardless of how they  were abused or neglected. Past research has shown that different types of abuse tend to occur together -- if you're sexually abused, you're likely to be emotionally abused, too, for example.  (Pears, Kim & Fisher, 2008 -- [LINK]) Some recent research has found that different combinations of abuse tend to produce different types of problems for people.

Continuing the work of Pears, Kim and Fisher, Berzenski and Yates (2012) -- [LINK] studied a large number undergraduate students who reported on childhood maltreatment and current adjustment. Results suggested that specific combinations of different types of abuse have different associations with different outcomes. Emotional abuse, alone or in combination with other types of abuse, was especially  related to psychopathology  (e.g., anxiety, depression), while a combination of physical and emotional abuse was most strongly associated with conduct-related problems (e.g., substance use, risky sexual behavior). These findings have significance for understanding and classifying experiences of maltreatment.

May 6, 2012 -- Biology or Experience -- Which came first?
Biological disorder or childhood trauma as causes of adult mental illness -- does childhood abuse contribute to the development of mental disorder, or does neurophysiological disorder make one more likely to suffer mental disorder? Or does pre-existing biological vulnerabilities interact with childhood abuse to lead to later adult mental disorders such as major depression (MDD) and borderline personality disorder (BPD). This is a crucially important question in terms of how patients, sufferers of "abuse induced" mental illness, are regarded by care providers. It could affect whether or not abuse-related disorder is regarded as an "adjustment disorder", or as other types of disorder, such as BPD or MDD. Considerable research in the past, examining factors related to "hardiness", have suggested that pre-existing vulnerabilities are what's fundamentally the cause of such mental illnesses.

Recent research by Carvalho Fernando and colleagues -- [LINK] , from Blefeld Hospital, Germany, has compared healthy control participants to BPD and MDD patients and found that such patients exhibited both enhanced cortisol concentrations before and after the administration of 0.5mg dexamethasone. Higher cortisol levels were positively correlated with a history of childhood trauma, current dissociative symptoms and severity of borderline and depressive symptoms. Statistical prediction (regression analyses) revealed that some aspects of early trauma were associated with cortisol release before and after dexamethasone, whereas psychopathology did not contribute to the regression model. Thus, these researchers argue, the well known disturbances in neurophysiological (HPA) function associated with MDD, BPD, and also likely PTSD, appear to be related to childhood trauma rather than to psychopathology in adulthood. Exposure to childhood trauma thus may contribute to long-lasting alterations in HPA activity and might enhance the risk for the development of later mental disorder -- the causal chain would then be:  childhod trauma -> neurophysiological dysfunction -> adult mental disorders -- rather than neurophysiological dysfunction + childhood trauma -> adult mental disorders -- which would seem to highlight the essential need to prioritise treatment the effects of childhood trauma rather than to treat neurophysiological dysfunction (through drugs) alone, which is particularly problematic, given the often limited range of treatments available -- see my previous post, regarding the importance of need for, and provision of, choices of treatment and this study -- [LINK]

May 10. 2012 -- Psychiatric Mislabeling Is Bad For Your Mental Health
.. in fact it can be soul destroying!
The title to today's post was the headline on today's version of Dr Allen Frances blog on Psychology Today - DSM-V In Distress -- [LINK]. It has particular relevance for adult survivors of childhood trauma for which there is currently no accepted diagnostic label. Dr Frances was chair of the taskforce for the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) and was commenting on the results of field trials of the reliability of diagnostic criteria for the upcoming Fifth Edition of the Manual (DSM-V), which showed that even criteria for "well-accepted" diagnoses such as Major Depressive Disorder are performing well below acceptable standards. This certainly does not bode well for the future diagnostic status for disorders caused by childhood trauma and neglect.  Dr Frances, a psychiatrist himself, wasn't speaking "out of turn".

 As Dr Frances notes: "An inaccurate diagnosis can be a disaster- leading not only to inappropriate treatment but also to stigma, ruined self confidence, reduced ambition, needless worries, despair about the future, and a deeply injured sense of self"; This is one of the factors that motivated the National Child Traumatic Stress Network to see a new diagnosis introduced in DSM V  "Developmental Trauma Disorder" -- [LINK] for child and adolescent victims of abuse and neglect.  I would argue that the plight of adults with such disorders is even worse than that children -- adults are much less likely to receive childhood trauma-related treatment, and untreated effects of disturbed attachment, such as caused by childhood abuse and neglect, can last all a person's life, even up to the time they start dementing! (Browne & Schlosberg, 2006) -- [LINK]. Along the way such adults can attract diagnoses of  "Personality Disorder (especially Borderline PD -- a particularly stigmatising diagnosis), "Adjustment Disorder", "Alcohol Dependence", "Addiction", and not just (in fact rarely) the diagnosis "Postrraumatic Stress Disorder" -- all, to varying degrees, stigmatising diagnoses  -- not surprisingly, those charged with diagnosing (psychiatrists) are amongst the foremost people stigmatising adults presenting with problems arising from childhood trauma.(Adams, 2010 -- [LINK]; Jutel, 2009 -- [LINK],Lincoln, 2006 -- [LINK]).

Adult survivors of childhood adversity and trauma are well known to have substantially limited and impaired lives as a result of their childhood experiences (Goodman, Joyce, & Smith, 2011 -- [LINK]; Smith & Smith, 2010 -- [LINK]). And that is without the psychological effects of psychiatric diagnosis, and especially without the effects of inaccurate psychiatric diagnosis. It may be "natural" (or lazy and judgemental?) to slot people into categories, and not think of them outside those categories (especially not as people from and within particular contexts), but people ARE people, they ARE not the problem -- best expressed in the title of the article by Michalak -- [LINK]: "It's something that I manage but it is not who I am".  Yet all too often, that's how adult survivors of childhood trauma are regarded. Why do psychiatrists so stigmatise adult survivors? (for a discussion of psychiatric stigma associated with personality disorder see Nehls -- [LINK], and Lincoln -- [LINK]). Well, we don't make "good patients" --  we often have difficulty REALLY talking about our problems (though we can skim the surface and give the appearance that we are when we're not -- we're too burdened by shame to really say what we're doing "wrong" so we can cope), we DO all those socially unpleasant things like abuse alcohol and other drugs, we do things impulsively like commit silly crimes -- my brother stole to try to buy so-called friends -- we're often "not compliant" with the treatments psychiatrists prescribe, we often don't respond all that well to the treatments (usually drugs) that psychiatrists prescribe, we often know more about "the problem" than what they do, we're generally not all that good at so-called therapeutic relationships, or any sort of relationships, especially when those relationships are really under somebody else's control -- something so well described in van der Kolk's 2005 article -- [LINK].

How can we try to avoid the problems associated with "mislabeling" -- first, and foremost, try to avoid the problem of growing up with psychological disorders as a result of childhood trauma. If you already suffer from those, or you're trying to avoid future problems, try to find your own "place of safety" -- especiallly one that's thought "healthy" by psychiatrists, and most importantly, if you can, stay well clear of psychiatrists -- my next post will be on "Finding a Place of Safety".

May 28, 2012 -- Finding a place of safety -- or not! -- at Ashburn!!
Last time, I promised to provide some guidelines about "finding a place of safety", well, as you've seen from "My Story" I believe in being honest! and you know I've sought help from hospitals before -- that includes from Dunedin's Ashburn Clinic!  Well, sadly, fat lot of good, and risky, that turned out to be.  I tried to kill myself a week after getting out of Ashburn, and you know I hope you can learn from my experience, and I've dedicated my site to "Wayne", someone I knew from Ashburn, who killed himself in August of last year. I met Wayne in Ashburn, we grew to be friends, largely because of how helpful he was to me, and how unfortunately similar our time, and experience, in Ashburn turned out to be be.

• a lack of adequate up-front assessment, resulting in (this won't be a surprise to those familiar with my website or this blog) -- inadequate and inappropriate treatment, often resulting from an outdated conception of psychological trauma, and complex trauma in particular

• a years-old awareness of clinical research literature -- I did complain to the Health & Disability Commissioner about Ashburn but was assured their approach was "research-based" -- this is like saying that giving a blood transfusion to someone who's hemorhaging is research-based -- after all, we know the human body has a lot of blood and that losing too much blood has "unfortunate consequences", like death -- this is "research-based", William Harvey studied the systemic circulation of the blood supply in the 17th Century,  so is Ashburn's approach "research-based", although in this case the research is only thirty years old -- but would you want your loved one being subjected to such outdated treatment? Would you want a tranfusion of blood that hadn't been matched to YOUR blood supply, risking incompatibility and "unfortunate consequences", like death?

  The clinical guidelines and literature you'll see discussed on this site is years ahead (like it's current research that's being discussed!) of what Ashburn practice is based on. You have a RIGHT to demand your therapists keep up to date with clinical research -- I do, so it's available to anyone who's "professional" enough to assume their required responsibility.

• a lack of trained staff -- Ashburn "trains" staff, especially psychotherapists, yet they practice everyday in the absence of direct supervision, yet the patients are encouraged to regard them as "expert staff"; the senior nurses involved with everyday therapy have little, or no, training in psychiatric nursing, let alone formal qualifications in counselling. There are some exceptions, but not surprisingly, GOOD staff usually go elsewhere fairly quickly -- well-intentioned staff are not the same as GOOD staff.

• the professional staff there are often not members of relevant professional associations (like the NZ Psychotherapists Association - NZAP) -- why should they be? well, then they might be professionally accountable to their peers -- but Ashburn don't want that do they, and as a result, their assessments are often devoid of ciients' life contexts, being heavily medical-model instead (I was "assessed" - I should have been receiving counselling, but no counselling was ever received -- by pysychotherapist "Richard" there, and ended up feeling he'd make a very good entomologist -- I felt stuck like on an insect on the end of a pin by his "counselling" and report of his assessment, but it did me no good whatsoever, as it didn't review me in the context of my life history  -- something directly contrary to the guidelines of the NZAP and the NZ Counsellors Association.

• there's a severely restricted range of research-validated therapies -- even though Ashburn says it functions according to a psychodynamic model, there's a restricted range of psychodynamic therapies -- there's nothing like Spermon's therapy for complex trauma (Spermon, Darlington, and Gibney, 2010); there's nothing like Fonagy's Mentalization Therapy (Bateman & Fonagy, 2003) -- despite having a speaker about it at a conference held at Ashburn -- Mentalization's an essential element of research-supported psychodynamic therapy for those with histories of disturbed attachment -- the majority of Ashburn clients. There are no contextual therapies like Dialectical Behavior Therapy or Acceptance and Commitment Therapy -- which extensive clinical research supports. There's a lack of respect for men's particular needs, like gender respecting therapy for adult male survivors of chilhdood sexual abuse -- MSSAT is particularly shunned by Ashburn staff -- it's a "men's agency" and Ashburn errs on the side of blind cruelty and "political correctness", at the expense of male victims. 

• Treatment for those with subtance abuse problems bears no relation to motivational interviewing (MI), 12-step (AA), or other treatment service philosophy -- both AA and MI are well accepted approaches in the substance abuse counselling field; instead, Ashburn's approach is heavily confrontational -- which is DEFINITELY NOT supported by the clinical treatment literature, but likely counter-productive -- leading to MORE substance abuse. In the majority of substance abuse treatment services, disclosure of still having supplies is NOT reported to Police, allowing the person to rid themselves of drugs, and enter recovery without unnecesssaary barriers -- this however is NOT Ashburn policy -- DON'T go there unless you want to be reported to the Police, or to your parents -- "patient confidentiality" is not a principle Ashburn believes in, unless it serves THEM, rather than the patient -- three years after being there I STILL can't get access to my clinical records -- something I'm taking to the Human Rights Review Tribunal.

• there's no respect for Client-Directed, Outcome-Informed (CDOI) approaches and patients' perspectives (see Fluckiger, et al, 2012) -- Ashburn expects patients to act in accordance with a strict expert-subject role relationship -- but who's the real expert in what's going on for patients? You, the patient suffering, or someone else without your life experience?? Thus, Ashburn staff clearly stigmatize patients and patients' therapy suffers due to patients not being respected and not being able to take part properly in therapy as a result.

• sadly, those in NZ are devoid of many of the rights available elsewhere -- you do NOT have a right to your clinical records -- that's for those at places like Ashburn to decide -- in Australia, your records must be made available to your clinical representative if an agency like Ashburn decides it's not in your best interests to receive those records directly -- thus such agencies evade even any sense of accountability

• Ashburn staff exercise shame-based approaches (instead of validation-based approaches, see Linehan, et al, 2002) to manage clinical milieu, with damaged patients exacting damaging influences on others, or are just "neglected" -- I had difficulty with one patient's negative transference with me due to my reminding her of her father -- I advised psychiatrist Stephanie as soon as I became aware of this, but when I left, eight months later, the problem still had not been addressed, and this patient's, and my own, therapy was all the while being damaged in the process.

• Ashburn is primarily profit-driven, as soon as you look as if you're leaving you're quickly dismissed and your ongoing care is not assured; further aggravated by Ashburn staff repeatedly saying, in effect, "we're the best", and repeatedly criticising and deriding other services -- quite unjustifiabily -- I've always had excellent care (by the nursing staff) in Psychiatric Services in Dunedin -- far better than I ever had at Ashburn, just the psychiatrists in public services here have been lousy, in MY experience, especially the "intellectual leader" of Psychiatric Services in Dunedin, Paul Glue, who once said "they're the best there is", referring to staff at Ashburn -- well, compared to you, Paul, ANY other psychiatrist is good, that's true, but certainly Ashburn staff psychiatrists are very far from being good, or competent.  Certainly, we need to, and can, largely, rely on the nursing services in the public system, rather than being afraid of those services as a result of the derision they receive from Ashburn staff.

• ALL OF THESE CONCERNS HAVE BEEN REPORTED TO ASHBURN, AS WELL AS THE PUBLICATION OF THESE CONCERNS ON THIS WEBSITE -- WITHOUT ANY CHALLENGE IN RESPONSE! AFTER MONTHS!!
  -- Do you really want to see those you care about go there?

So, so far as "finding a place of safety", the first and most important thing is to not put yourself in a more difficult position than you  were in originally -- Ashburn IS a far worse place than you're in, if you're in recovery, and no longer being sexually or physically abused. Many nursing staff go there, rather than local services, in a wish to avoid the stigma rife in the system if you're a working professional (Adams, et al 2010 -- ), but quickly (like overnight!) leave as soon as they have their first experience of Ashburn. But, if you've suffered complex trauma, or emotional abuse, going to Ashburn will be yet a continuation of your history of abuse.

Come on Ashburn -- and you psychiatrists there!  Challenge me and my "allegations" above in a court of law, but respect my right to my records so I can fight my case!  No challenge means no contest.

Not surprisingly, the guts have been ripped out of Ashburn in recent years -- the lion's share of its income used to come from ACC due to clients with sensitive claims receiving counselling there -- this doesn't happen anymore, due to "financial" reasons -- Ashburn couldn't justify its treatments for ACC clients.  Ashburn -- a lovely location, a great, much needed, potential service, but currently going to waste in the hands of its psychiatrist / administrators.

As my website users will know, this post, and its more positive recommendations, have been delayed by a more thorough review of meta-analytic studies looking at treatment outcome studies for trauma and complex trauma -- more on the results of that in my next post!

References

Adams, E. F. M., Lee, A. J., Pritchard, C. W., & White, R. J. E. (2010). What stops us from healing the healers: a survey of help-seeking behaviour, stigmatisation and depression within the medical profession. The International journal of social psychiatry, 56(4), 359–370. doi:10.1177/0020764008099123

Bateman, A. W., & Fonagy, P. (2003). The development of an attachment-based treatment program for borderline personality disorder. Bulletin of the Menninger Clinic, 67(3), 187–211.

Flückiger, C., Del Re, A., Wampold, B. E., Znoj, H., Caspar, F., & Jörg, U. (2012). Valuing clients’ perspective and the effects on the therapeutic alliance: A randomized controlled study of an adjunctive instruction. Journal of Counseling Psychology, 59(1), 18–26. doi:10.1037/a0023648

Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., Heagerty, P., & Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and alcohol dependence, 67(1), 13–26.

Spermon, D., Darlington, Y., & Gibney, P. (2010). Psychodynamic psychotherapy for complex trauma: targets, focus, applications, and outcomes. Psychology Research and Behavior Management, 3, 119–127.

June 21, 2012 -- Finding a place of safety -- or the experience of quiet peace
My apologies for taking so long to write this post -- I think I was expecting too much of myself, after seeing posts like the following from Storied Mind -- [LINK] -- I didn't "feel" as if that was THE answer, and I think I was expecting myself to provide you with THE answer to how to find THE place of safety for yourself, as if THE place of safety really exists, for anyone!  I'm sorry, I don't believe that now. I think the reason I was finding it so hard was because I knew I had lost A "place" of safety and no longer felt as if I had one, with loss of my work status, my inability to pursue formal study -- both crucial in "escaping" from my early adverse family circumstances and finding a grounding in the "normal" world.

But, of course, and thankfully, there is no such thing as "a place of safety", there are certainly "places" where we feel safer, but this feeling, of safety, of security, of the sort of peace referred to in the Storied Mind blog, really have nothing to do with "places" (though we can and often do unconsciously respond with greater feelings of inner peace to some circumstances in some places).  And it really has nothing to do with a supernatural ability to "stop time".  Rather our relationship with time alters, and we can develop this ability to alter our relationship with time, so that we become more able, and more flexible, in the range of experiences we can have with time; and we can develop the ability to bring about this change IN A MOMENT.  Therein lies the first part of the key "in A moment", or rather THE moment  -- yes, I'm talking about -- MINDFULNESS, mindfulness in the present moment, mindfulness of the present moment, the sense of time stopping comes from the fact that you're just less mindful of the past experiences you've had, you're less aware of the future experiences you may be afraid of, not that these inner experiences go away, but your relationship with them is different, you're less invested, emotionally and intellectually, in them.

Just how did I come about this greater sense of peace? -- because I truly had been experiencing a period of great emotional distress. 

I became actively involved in taking action in the service of values I hold dear. I communicated to others my feelings about my past experience of sexual abuse, and my current circumstances -- communication in such a way can sure do a lot to help one confront and accept the feelings one has been avoiding for so long; and engaging in committed action can help one feel worthwhile, valid, and doing something worth doing -- that you, as you are, can still do something worth doing, even in the context of NOT having your previous place of safety -- you can be very afraid, yet still carry on, on faith -- like Lou Reed said in his song "you gotta have faith",  even when all those socially conventional things aren't deliverin', you can still go on.

What am I doing that's values based?  My friend, Wayne, a victim of childhood abuse and trauma died in August last year, he was a "male survivor of sexual abuse", and I hope to contribute to the story of survivors of childhood abuse becoming better known and understood. Coming up, I think on Saturday 30th June, is a newspaper story -- I spent some time yesterday talking to a journo from the Otago Daily Times, here in Dunedin, and he's writing a story about the experience of adult survivors of childhood sexual abuse and this will be your chance to see me "in the flesh" -- I'm seeing a photographer tomorrow, as I've given my consent for both my name and my photograph to be included with the story.

And the feelings? Well, put it like this -- there's a metaphor in Acceptance and Commitment Therapy about "leaves on a stream" -- the feelings are like the leaves, it's not that they don't touch, and don't disturb, the surface of the water, but the water flows along on its course, "where it's supposed to go", where it wants to go, given the nature of the water. And yes, it does help with those unpleasant feelings, although that's not WHY I'm taking the valued action -- it's just my experiencing a side effect of taking the action. And it doesn't come immediately, but it's at least potentially available to me WHEREVER I am, it's not dependent on a "place" of safety.

June 26, 2012 -- Psychologists Board -- Shame on You!!
So you've decided you should go and see someone to get some help -- your problems have finally caused you to suffer a toll you're not wanting to pay anymore -- job, relationship, substance abuse, suicide attempt, a friend committed suicide and you've decided that shouldn't have needed to happen -- like what happened to me, to get me to start this blog / website.  But, you've been abused by those in positions of power in the past, so who can you trust -- let's see.

I was seeing a psychologist from the Dunedin Hospital service for counselling, Simon Kuttner, but certain things became evident (like his acting without supervision) so I stopped seeing him and lodged a complaint for "inadequate and inappropriate treatment" with the HDC and the Psychologists Board. In the course of the  enquiry, whcich went nowhere, Kuttner revealed details from my clinical  record, despite being given explicit instructions NOT to do so.  This never resulted in any action being taken by any "responsible" party, like the Psychologists Board.  So, if you wish to see someone, whatever you do, treat it as a business decision -- caveat emptor!  Only problem will be that if something goes "wrong", short of your being the victim of a crime, stiff cheese! 

The Health & Disability Commissioner acts as an apologist (that's someone who gives half-baked excuses, not someone who makes apologies);  the professional boards defend their members (fee-paying members), not the Public, and the so-called "professionals", well, not very professional -- part of the defining characteristic of a professional is that they have a body of knowledge, and a set of language and reasoning skills based on that knowledge, that distinguishes them from the general public . Well, what if they prefer following half-baked philosophical mumbo jumbo that's anti-scientific? Well, that's what the Psychologists Board of New Zealand allowed Simon Kuttner to foist on this innocent guy, no questions asked, no need for justification. Never worry about the fact that it's actually against that Board's Code of Ethics for Psychologists to pressure clients to swallow the psychologist's pet philosophies, free of scientific basis -- Simon, you see, practises a form of philosophy   called Anthroposophy --  look that up in Wikipedia and you'll see many of its practitioners regard it as a religion;  and then see what Wikipedia says about its approach to Science -- definitly NOT pro-Science, and this is someone who is obligated to base his approach on scientific evidence?!  A glaring contradiction between professed philosophy and actual practice.  In actual practice, Kuttner's skills are so poor that, were he to have studied Psychology when I did, he would not have passed second-year counselling, let alone be allowed to practise professionally, But, then again, it's that fee-paying thing --- only this time, the University that allowed him to graduate.  And clients, in the Public system, don't pay fees, so should they have to be grateful for ANYTHING they get, well obviously, Kuttner and the Psychologists Board think so.

And Kuttner complained that I had allegedly improperly investigated him on the internet -- well, as you can see, I am who I am, it's (mostly) all out there in the public arena, on the internet, and so far as what constitutes "improper investigation" -- at no time have I sought private, confidential information ahout him, and like everything else, he needs to improve his knowledge of professional matters -- look here about information it's proper, and prudent I would suggest, to find out about your therapist:  [LINK]-- yes, that's right -- therapists have a right to confdentiality, and there are definite limits on what they can claim is confidential -- so, you don't have to be as up-front public as I am, but you, and therapists, can't claim confidentiality for those same things you claim public credit for! As Kuttner did for his charitable activities with Antroposophy --  good works for ill-perceived "reasons", but more likely just self-aggrandisement.  Clinical records, though, ARE, confidential, Kuttner.

And Psychologists Board? -- shame on you for allowing these things to occur, and for abrogating your responsibility for not ensuring adequate quality of care for THIS member of the Public.  Not only Kuttner needs to be reminded of ethical responsibilities, but especiallly the Board.

Both Ashburn Clinic (see my earlier post),  and the NZ Psychologists Board have been made aware of my posts on this website concerning their actions, or lack of them.  So, what?  I'd like to encourage readers to check out this song by Elena Mitrano on YouTube: [LINK]  -- you're not alone.  YOUR VOICE deserves to be heard, and MUST be heard -  you WILL stand a bettwr chance of recovery if it is. 

van der Kolk's great paper on Developmental Trauma Disorder -- [LINK] -- has so far failed to yield the changes sought -- this is what motivated this site -- inadequate and inappropriate treatments being meted out to the sufferers of trauma-related disorders everyday -- why?!   Why did everyone say, when I presented my Ph.D. research proposal to them "it's not in my backyard" (so why should I do anything about it?), or "Russell, you're too far ahead of the game" -- except that YOU are the ball being kicked around in the game -- the "real players" -- the HDC, the Psychologists Board, Kuttner, will go off and have a beer together after "the game" is over, and won't attend our funerals, so, are we alone, not so long as we are there for each other.

I'd like to leave you with a quote from Judith Herman,
"originator" of the term "Complex Trauma":
"It is very tempting to take the side of the perpetrator.  All the perpetrator asks is that the bystander do nothing. He appeals to the universal desire to see, hear and speak no evil.  The victim, on the contrary, asks the bystander to share the burden of pain.  The victim demands action, engagement and remembering."   (Herman, 1992) -- [LINK]

And the likes of the HDC, the Psychologists Board, Kuttner, they take the on the role of the perpetrator -- You gotta have  faith, in yourself, in yourself, because YOU know the truth of what was done to you, and YOU CAN see this through. Just as well. because you'll have to do it despite the actions of those at Ashburn Clinic, with the HDC, at the Psychologists Board, or at the hands of shonks like Kuttner.

June 30, 2012 -- Consequences of Biological Vulnerability
In a paper sure to please many psychiatrists, with a propensity to always place biological factors at the forefront of arguents for the causes of mental illness, and albeit in a paper written by those with financial interests in drug treatments, Saveanu and Nemeroff (2012) -- [LINK] -- available [LINK] -- argue that sufferers of childhood trauma-related depression may have a genetic vulnerability so that they may be responsive to different treatment strategies than depressed patients without childhood adversity. Based on current findings, they argue, treatment strategies should be multimodal and include the following:

• Psychotherapy that addresses a number of domains, such as emotional regulation, cognitive reframing, careful exploration of past traumatic events, attachment, and interpersonal relationships in a safe and trusting therapeutic environment.

• The therapy should likely be longer term in order to effectively impact those domains.

• Pharmacotherapy that will be effective in quieting the body’s hyper-responsiveness to stress and reverse epigenetic modifications induced by trauma and stress.

• Environmental interventions that provide a support network (maternal care, a positive family environment, the support of a close friend) have all been shown to attenuate the impact of childhood abuse.

(Of course, these are also consistent with those of van der Kolk originally for children and adolescents -- [LINK].)

The recommendations are certainly consistent with the recommendations of the expert panel surveyed by Cloitre et al (2011) --- [LINK]- available [LINK].  What is missing from Cloitre et al's statement, concerning needed duration of treatment, but is more clearly spelled out in that of Saveanu and Nemeroff, is the likely need for longer term treatment, provided that that treatment is tailored to the specific needs of the patient, identified by comprehensive assessment across a number of areas of functioning; likely "staged", so that "treatment enabling" goals of intervention are targeted initially (for example, targeting emotion regulation initially -- e.g., Cloitre [LINK] -- available [LINK]). Of course, this is also the result found by Kriedler and Einsporn (2012) -- [LINK] .  These authors' study sample included women from 6-month therapy groups (n = 42) and a comparison group who completed 12 months of therapy (n = 114). When outcomes attained by the 6-month group were compared with those of the 12-month group, those in the 6-month group showed significantly greater gains in self-esteem, symptom change, and posttraumatic stress disorder symptoms. In addition, although participants in the 6-month group improved more in depression scores than those in the 12-month group, the difference was not statistically significant. The results of this study indicate that intensive 6-month group therapy for female survivors of CSA may be even more beneficial than less intensive 12-month groups. It is likely that treatment for Complex Trauma may be longer.

Consideration of the overall results of Cloitre et al, Saveanu and Nemeroff, and Kriedler and Einsporn, go a long way towards defining what is adequate and appropriate treatment for childhood trauma related disorders (whether the disorder be PTSD or chronic / remitting depression -- there are some indications that gender may be one factor determining whether or not the resulting disorder is one or the other -- see my initial thesis proposal).  Moreover, they go a long way towards making the limit allowed on therapy sessions by the ACC, in NZ (16 sessions), look woefully inadequate. In the last 12 months, of 1151 men who have received ACC "Sensitive Claim" counselling, only 2 (two) have been approved for more than 16 sessions.  The results of this research also make the "treatment" offered by Dunedin's Ashburn Clinic (see my earlier post on this -- [LINK]) look the farce it is, especially the so-called treatment offered to male patients there.  But very clearly, the research also clearly reflects the fact that intensive treatment, as Ashburn Clinic SHOULD be offering,along the lines outlined by Saveanu and Nemeroff, is definitely needed.

July 4, 2012 -- Anxious Depression -- Medication?
In my last post, I reviewed the recommendations of Saveanu and Nemeroff (2012).

Today, I'd like to briefly discuss one of them:

• Pharmacotherapy that will be effective in quieting the body’s hyper-responsiveness to stress and reverse epigenetic modifications induced by trauma and stress

The "standard" drugs used to treat PTSD / trauma are the SSRI anti-depressants.  These rarely work all that well, at least in my experience. The most "success" I've had is with a combination of Venlafaxine (Effexor) and Buproprion (Zyban) -- the latter being "good" due to its managing the anxiety symptoms I suffer. Generally, though, my attitude tends to be the same as that of my fellow blog writer John on "Storied Mind" -- [LINK] -- "stay off 'em if you can". 

One of the changes being considered for the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) Version 5 is the introduction of a mixed anxiety / depression disorder -- [LINK].  The recommended diagnostic criteria for this disorder include: "The patient is not suffering from any other mental disorders recognised by DSM-5"  This is farily standard diagnostic practice, but does little, really, except help serve one of the possible uses of DSM-5 -- produce relatively "pure" groups for research.  

However, during one of my previous stays in the local "Mental Health" acute unit, the psychiatric registrar suggested, and I started taking, "prn" (as needed) Quetiapine, "to help me sleep" -- it helped, although taking it "too late" at night left me feeling too sedated the next day.

Now, in the latest issue of the journal Depression and Anxiety, Thase et al -- [LINK] -- discuss the use of extended release Quetiapine in patients suffering from depression, some of whom also suffered high levels of anxiety symptoms, though they DID NOT use the recommended DSM5 criteria. As they put it: "Quetiapine XR monotherapy improved symptoms of depression in patients with higher and lower levels of anxiety."

One caution, the last time I was in hospital the psychiatric registrar at that time was not in favour of prescribing Quetiapine -- "I generally don't prescribe "anti-psychotics" (my quotes) to people not suffering psychosis"  -- well,, sorry to say, thare are NOT such things as "anti-psychotics" -- biological psychiatrists have long been in search of this Holy Grail, but it's simplistic to describe the drugs given to patients with psychosis as "anti-psychotics" -- mostly, they are major tranquillizers, some with effects on both physical and cognitive symptoms.  So, my recommendation, if you wish to try this medication out -- bring this information to the attention of your treating doctor, and simply explain that, for you, symptoms of BOTH anxiety and depression are being experienced and are problematic.

I have requested the Thase et al article from the author and will make it available for you to provide your doctor as soon as I have it -- contact me at AdultSurvivors.org.nz if you'd like to have a copy for yourself.

All the above "technical" considerations need to take place, in the making of a decision between your medical care provider and yourself of all the other "non-specific" factors relevant to treatment including (but not limited to): the need for a collaborative partnership the two of you, including that a clear and full discussion is held about options available, and the possible need to "stage" different treatments for different times -- perhaps medication immediately, then medication PLUS counselling, then moving on to counselling alone at some future time; the need for "titration" of the dosage taken -- carefully monitoring effects of dosage, starting on a small dose, altering dose depending on improvement in symptoms versus cost in side effects; incorporating drug treatment and counselling in a mix of other "interventions" or lifestyle changes, including peer support from those with similar problems -- for general tips see here -- [LINK] and try the other resources here -- [LINK]- good luck, good health, let me know how you get on!

July 7, 2012 -- Developmental Trauma Disorder - Update
I've been struggling for a while trying to get uptodate information on what's happening with the field trials for the proposed new diagnostic classification for the problems suffered by children who've experienced interpersonal trauma -- Developmental Trauma Disorder -- first discussed in great, and moving, detail by Bessel van der Kolk in 2005 in the journal Psychiatric Annals. This article and the most recent "Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis", by D'Andrea, W., Ford, J., Stolbach, B., Spinazzola, J., van der Kolk, B., (American Journal of Orthopsychiatry,  2012, Vol. 82, No.2, 187-200),  are available for download here -- [LINK].

Well, yesterday I got the following email from Regina  Musicaro, Clinical Research Coordinator, at The Trauma Center, Justice Resource Institute, Brookline, MA, USA:

"The field trial is still in progress and data collection will not likely end until late fall.  Then we have to analyze data across all seven sites nation-wide.  In my experience, projects of this caliber take very long to complete (much longer than we want!) and my guess is that the full results will be out in a year.  This is just a guess, of course, and the goal is to be ready much sooner.  Thank you for your interest in the field trial and I hope to get better answers ASAP."

This means, unfortunately, that the diagnosis probably will not be appearing in the new edition of the Diagnostic and Statistical Manual, Version, of the American Psychiatric Association.  Sadly, this might also mean that doctors will be reluctant to use the diagnosis when the field trial results are in, regardless of what the results are, with negative implications for chances of reducing the inappropriate and inadequate treatment children currently receive due to not having a "recognised" disorder, as discussed in the original submission (see above link).

July 12, 2012 -- Developmental Trauma - In DSM5?
Great news, on at least a couple of fronts today.

"Last night"  I received the following from Wendy D'Andrea, author of this important study "A naturalistic study of the relation of psychotherapy process to changes in symptoms, information processing, and physiological activity in complex trauma." -- [LINK], as well as the latest article on the diagnosis "Developmental Trauma Disorder" -- "Understanding interpersonal trauma in children: why we need a evelopmentally appropriate trauma diagnosis" -- [LINK]:

"The good-ish news with the DSM-V situation is that, as I understand it, they plan to release continuous updates, like software. So they are encouraging us that while it won't likely be there now, it may be in version 5.1 or something. The other good news is that the revised PTSD diagnosis includes a lot of the self- and relational-dysregulation symptoms we'd like to see in DTD. The best news of all is (if you ask me) that the DSM-V process has been so problematic across the board that it seems like it will eventually implode.

I'm happy to share that, with my colleague Greg Siegle, I've just gotten a really big grant from the NIH to study trauma's effects on the body across diagnoses through a new grant mechanism called RDoC. The grant mechanism makes a point of being "agnostic to the DSM." This type of grant, which is not tied to a given diagnosis but rather to trauma as a risk factor, is an unprecedented step in the right direction for the NIH, as it is looking more to commonalities in mechanism and life history rather than concrete, limited diagnostic constructs."

On another, LOCAL, front we have news that Kate Scott has had an important article published -- [LINK] -- in the British Journal of Psychiatry: "Childhood maltreatment and DSM-IV adult mental disorders: comparison of prospective and retrospective findings".  Professor Scott is an Associate Professor in the Department of Psychplogical Medicine / Psychiatry at the University of Otago.  This is an important and valuable contribution, this time by local researchers, to the field.  As the article's abstract begins, to define the problem:

"Prior research reports stronger associations between childhood maltreatment and adult psychopathology when maltreatment is assessed retrospectively compared with prospectively, casting doubt on the mental health risk conferred by maltreatment and on the validity of retrospective reports."

The abstract concludes:

"Prospectively and retrospectively assessed maltreatment elevated the risk of psychopathology to a similar degree. Prospectively ascertained maltreatment predicted a more unfavourable depression course."

In fact, as Scott notes in the article, for various methodological reasons, the findings were "conservative" the strength of the association was less strong than might exist "in reality"  -- and the childhood abuse - adult disorder association not limited to mental disorders such as depression, alone -- other studies have found such forms of childhood adversity as neglect, and physical abuse, are contributors such alcohol use disorders as heavy, episodic drinking -- Shin, Miller, & Teicher (2012) [LINK] -- and (personal communication) Scott advises that a similar effect is discernible in the local data, consistent with the other studies findings.

For far too long, the assumption has been made that these associations are made only by "personality disorder" self--interested unstable individuals. The research data in fact argue that this is in fact contrary to the truth -- victims of abuse who suffer disorders, and victims generally, may UNDER play the significance of such abuse factors in accounting for their problems -- this would be consistent with the effects of shame and "flawed self" perspective of abuse victims.

It is too early, for us oldies, who have been forced to suffer the consequences of psychiatric maltreatment in the past, to get excited by these developments, but hopefully it will mean that, for those "newly diagnosed" children and young adults,  the long misunderstood nature of trauma-related disorders will become better understood as such, trauma-related disorders, and not as "personality disorders", and that "adequate and appropriate" treatment will be forthcoming, and that the stigma such oldies as I have suffered, and that adult victims of sexual abuse, and other forms of abuse, have suffered, will also come to an end.

Further information on the "RDoC" -- Research Domain Criteria -- research scheme can be found here: -- [LINK]

As usual, contact me if you'd like copies of the articles cited.

July 15, 2012 -- Treatability of Chronic Depression
In an unsurprising conjunction, my most recent (automated) advisory of new research from PubMed -- [LINK] -- reports of new research showing:

• in-hospital psychological treatments added significant (but not major) benefit to usual care and structured pharmacotherapy -- Cuijpers et al, Clinical Psychology Review (2011)  [LINK] -- this was a meta-analysis and did not specifically address etiology of depression -- in fact, the meta-analysis found generally limited, and poor quality, studies existed)

• in a local study, Douglas and Porter, Psychiatry Research (2012) -- [LINK] -- treatment non-responders reported significantly more severe trauma than treatment responders and healthy controls , suggesting that the experience of childhood trauma in those hospitalised with depression can be detrimental to treatment success.

Clearly,

• patients admitted to hospital when suffering from depression should be assessed for history of childhood trauma, and if found to still be suffering such effects (and this decision should be based on more than the clinician's impressions -- D'Andrea et al 2012 [LINK])

• should receive treatment additional to "usual care" and structured pharmacotherapy, but (as noted in a previous post -- May 5, 2012 see -- [LINK]), such care should be agreed upon in a collaborative relationship with the patient, and the care provided with the patient's agreement and active cooperation -- this may need to be based on initial psychoeducational intervention (Feeny et al, 2009 -- [LINK], Jaeger et al (2009 - [LINK]

July 19, 2012 -- Substance Abuse and Trauma -- Sad Truths

Previously in my posts I highlighted the research report of Professor Kate Scott of the University of Otago, comparing prospective and retrospective sources of data, linking experience of trauma during childhood and later development of mental health and substance abuse, especially depression and drug abuse. I'm still in touch with developments in substance use disorder research in my home country Australia and today there was a report of a recent study -- [LINK] -- led by Glenys Dore and Katherine Mills of the National Drug and Alcohol Research Centre at the University of New South Wales. This study found that upwards of 80 per cent of patients admitted to psychiatric hospitals with diagnoses of depression and suicidal ideation, aggravated by active substance use disorder, have histories of childhood trauma.  Dr Mills, in a radio interview with Wendy Harmer on Australia Radio National -- accessible here -- [LINK] -- actually reports that the 80 per cent figure is actually a "conservative estimate" with the actual PREVALENCE of childhood trauma experienced by such patients likely to be even higher. Of crucial significance, Dr Mills points out, is that most of these patients had never previously been assessed, let alone received treatment, for such trauma.

I have previously worked in the AOD sector in New Zealand, and still "take part" in the Alcohol and Drug Discussion List Aandd Digest -- [LINK].  Approximately a year ago I put a request over the list asking for opinions as to whether (a) people in A&D Services (most commonly called Alcohol & OTHER Drugs Services) customarily asked about clients' histories of trauma and (b) if such services had a standard practice of asking about, and dealing with such history. I received only four replies -- only one said they "commonly" asked about such history (though this wasn't a practice all within that agency had) and NO ONE had a standard practice or policy about asking about and dealing with history of trauma -- clearly this is an area of practice that SHOULD BE but IS NOT.

In my last email I wrote that we ARE moving towards knowing what SHOULD BE basic essential standards of practice for trauma-related disorders in mental health settings. Clearly there are also practices that SHOULD BE standard in substance use counselling services but are NOT, NOT in Australia, and certainly NOT in New Zealand -- if you care about this complain, to your Health Service, to the Health and Disability Commissioner, and to your Member of Parliament.

July 21, 20112 -- Forget the past -- at our peril

Today, I'd like to "re-publish" a post I submitted to the American blog "the Higher Education Chronicle" in response to encouragement from a colleague who responded to my post to the PsyLaw - Psychology and Law discussion list in response to his re-posting of somethi g comparing NZ and US responses to breaches in scientific ethics -- the original post to The Chronicle, by Dr Carl Elliott is available here -- [LINK]

"A colleague posted the contents of the post on a professional list serve of which I am a member. The list is largely American in membership, though I live in Dunedin, as apparently does Dr Elliott. However, the end result of our experiences has left very different impressions on us. With apologies I shall submit, largely, the contents of my post to the listserv (PsyLaw -- for those psychologists interested in both Psychology and the Law):

Dore,G, Mills, K, Murray, RM, Teesson, M & Farrugia, P, 2012, 'Post-traumatic stress disorder, depression and suicidality invinpatients with substance use disorders', Drug and Alcohol Review, vol. 31, no. 3, pp. 294 - 302

The message, to me, is clear: if we let our "responsible public bodies" repeat the errors of the past, as they have done by their NON-response to the issues mentioned, grievous harm will befall many more innocents.

July 30, 2012 -- Emotional Abuse & Social Anxiety -- Tortuous Recovery

Childhood maltreatment has been associated with the development of a variety of adult disorders, both physical and mental, with the severity of symptoms experienced, reduced quality of life, and impaired functioning across diverse domains.  A recent study by Bruce et al (2012 -- [LINK]) has extended these findings to Social Anxiety Disorder (SAD).  This study further examined the impact of different types of abuse, and the impact of abuse on the outcome of drug treatment for the disorder. 

All types of maltreatment except for sexual abuse and physical abuse were related to greater symptom severity.

Emotional abuse and neglect were related to greater disability; and emotional abuse, emotional neglect, and physical abuse were related to decreased quality of life. Emotional abuse significantly predicted attrition -- dropping out of treatment. A time by emotional abuse statistical interaction suggests that for those who stayed the course, the impact of emotional abuse on severity of social anxiety weakened significantly over time.  If you have been emotionally maltreatment during your childhood you are more likely to drop out of treatment, but if you can "survive" the challenges of treatment you are likely to benefit from treatment "almost" as much as those who suffered other types of abuse.

Emotional maltreatment was most strongly linked to dysfunction in SAD, despite a tendency in the anxiety literature to focus on the effects of sexual and physical abuse. Additionally, individuals reporting emotional abuse were more likely to dropout from pharmacotherapy, but those who stayed the course displayed similar outcomes to those without such a history.

To me, this creates an obligation on therapists to not only know the effect of various types of abuse on treatment process, but an obligation to monitor, through direct enquiry of the patient, how the patient is feeling about therapy, about how they feel they are being treated in therapy, and to devise a more effective working relationship with the patient -- see also the recommendations of Steidtmann et al (2012 -- [LINK] and Fluckiger -- [LINK].

In my next post, I shall explore the implications of these, and possibly related, findings for possible strategies for conducting more effective therapy with victims of childhood abuse and trauma.

Next post: The three R's of Trauma Therapy -- Relationship, Responsibility, Resilience -- The Core Elements of Treatment

A final observation can also be made -- we are moving more and more towards having evidence-based standards of care for adults suffering childhood trauma-related depressive, anxiety, substance-use, other psychiatric, and physical disorders. But, given my experience of practice and research issues in this area in New Zealand, we are VERY far behind where we need to be, where we, in my opinion, should be. Given the absence of a current research evidence base to local practice, people have died, through suicide, and through trauma-related physical disorders, long before they should have, after having suffered cruelly, emotionally and physically, from trauma-induced symptoms.