BLOG POST ARCHIVES

Period:      till end July 2012 -- [LINK]

Aug 5, 2012      -- The Three R's of Trauma Treatment -- Relationship, Responsibility, Resilience -- Core Elements in Treatment

I recommend people review the excellent video by Mary Jo Barrett -- [LINK] --  Rarely do I come across something that I would unconditionally support to others. This video is one of the rare exceptions.

This is a crucially important topic for survivors of childhood trauma and abuse to understand and I am in the process of addinga page on it to my website -- [LINK] However, the "five essentials" listed by Barrett in her video include:

1. a recognition and acceptance, by the therapist and the client that "You have suffered, but things can change for the better"

2. Skills building -- such skills might include:

   • mindfulness skills -- making room to pause and make choices

   • communication skills
   • parenting skills
   • cognitive behavioural skills

   • an acknowledgement that coping required skills (even some "symptoms") which can still be used

   • integration skills -- integrating cognitive, spiritual, and bodily (sensorimotor, sensing and soothing type) functions

3. a strength orientation -- an understanding of how symptoms have worked in the past as coping skills -- and thus therapy involves a loss, of symptoms, but has benefits as well

4. the recognition by the client that during therapy "I felt safe" -- as the therapy was well structured and explained to the client whenever requested by the client, with the therapist regularly checking on the client's understanding and acceptance of therapy processes; and as a result, therapy was predictable, had known boundaries, goals, structure -- this feeling of safety is essential for change to occur, The therapist needs to say "You tell me how to act", and act in a collaborative, elaborative way.

5. therapy must involve the creation of "workable realities" -- requiring the therapist to know at all times what they're doing; the client is confident that the therapy is evidence-based; and involves the creation of a workable future, in a concrete, defined way, and not just positive thinking

Barrett quite rightly notes that being able to counsel effectively requires a lot of "energy", the capacity to expend energy yet bounce back to the task when required by the client, thus I view such "energy" as somewhat akin to "resilience" and thus the three R's -- the importance of a safe, collaborative relationship between therapist and client; the therapist being responsible for the qualities of this relationship between established and maintained; and resilience -- absorbing some of the effects of the trauma from the client yet bouncing back with support and guidance when required within the therapeutic relationship.

Sep 22, 2012       Drop the language of disorder

I must be on a roll lately -- going from one inspiring experience to another ;-)

I've written about the excellent presentation by  Mary Jo Barrett "The Five Essentials of Effective Trauma Treatment" -- [LINK]

More recently, I've started reading Mike Lew's classic "Victims No Longer" -- a book for male survivors of childhood sexual abuse -- available in the Dunedin Public Library 362.768 LEW -- great coverage of a broad range of issues, expressed in easy to understand, sensitive, insightful and dynamic -- I'd call it essential reading for all those who care about men who suffered sexual abuse as children -- although it's written primarily about the effects of incest, I found it still to be useful (yes, even for an old guy in his late 50's, despite my abuser being an older boy at school).

Most recently, I've just read Peter Kinderman's editorial for the journal Evidence-Based Mental Health -- Drop the Lanaguage of Disorder -- available here [LINK]

It's rare for me to read an article and immediately feel compelled to select portions for quoting -- this was my experience on first reading this brief article.  It's written by some of the MOST dynamic and, in my view, "psychologically healthy" academics and clinicians you're ever likely to see in a group -- Peter Kinderman, as first author, and Rich Bentall, both from Uni LIverpool, John Read, from Auckland,  and Joanna Moncrieff,  from University College London. Moncrieff and Bentall have for a long time been part of  the "Critical Psychiatry" "movement" -- well worth investigating if the traditional approach to mental health leaves you cold, as it does me.

I'll restrain myself, though, from quoting too much -- it's a brief article (only 4 pages), easy to read, and refreshing!

But I will quote the closing paragraph, and then strongly encourage you to read all of the article:

Clinicians are ... likely to be more effective if they respond to an individual’s particular difficulties rather than their diagnostic label.

You might also find the following articles interesting, relating to the basis of the contribution of childhood adversity to adult difficulties:

Johnson, C. Y. (2012, September 21). Scientists begin to unravel the long-lasting biological effects of early-life adversity, social isolation. The Boston Globe -- boston.com. Boston, MA. Retrieved from http://www.boston.com/news/science/2012/09/21/scientists-begin-unravel-the-long-lasting-biological-effects-early-life-adversity-social-isolation/j28yh2lHWj3P8vYY1CpGPO/story.html

             available here: [LINK]

Read J, &Bentall RP. (2012) Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. Br J Psychiatry. 200(2): 89-91. Available here [LINK]

As the Read and Bentall article reminds us:

"Psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors for psychological distress"

You might also find the following interesting if you have questiions about alternatives to drug treatments:

The Guardian newspaper : Friday 21 September 2012

The doctors prescribing the drugs don't know they don't do what they're meant to. Nor do their patients. The manufacturers know full well, but they're not telling.

Andrews, P. W., Thomson, J. A., Amstadter, A., & Neale, M. C. (2012). Primum Non Nocere: An Evolutionary Analysis of Whether Antidepressants Do More Harm than Good. Frontiers in Psychology, 3. doi:10.3389/fpsyg.2012.00117  [LINK]

Sep 28, 2012       Safe for Survivors -- Not in Dunedin!

The expression "fly in the ointment" is, I guess, a description of where something that is meant to help in healing is spoilt by something that is unhealthy, or even harmful, to the person using the ointment.  Sadly, that is the situation confronting many survivors of childhood sexual abuse in Dunedin.  I've written before about how unhelpful, even harmful, Ashburn Clinic is for male survivors of childhood sexual abuse. At the time I wrote that post I was hopeful that appropriate services for survivors could be obtained through the assistance of the Male Survivors of Sexual Abuse Trust. Today I must write that that hope was misplaced.

It's easy to say that services from a particular agency are "inferior" yet fail to achieve any change in those services -- as I've written about in the past about the LACK of response I've had to complaints I've lodged with the Psychologists Board and the Health and Disability Commissioner -- there are NO specialist standards in place for adult survivors -- leaving the adult survivor unprotected as a consumer of such services -- so long as "illlegal" practices aren't occurring, the consumer is helpless, without a means of redress, or even channel for pursuing a complaint.  Barring illegal activity, it's OPEN SLATHER -- therapists and agencies can do what they please, and do.

BUT -- consumers, yes, you're alone when it comes to struggling with agencies (and government) services, BUT there are steps you can take to protect yourself. And funders (since agencies providing such services are often charitable trusts), PLEASE DON'T  FUND such agencies until and unless they have adequate provisions in place to protect consumers.

So, how do you find "safe therapy", or at least "safe support"?

I'd recommend the following as some good sources:

In general:

GoodTherapy.org -- here [LINK]

which recommends at least the following

How to choose a counselor or therapist:

• Does the therapist have experience helping others with the particular issues for which you are seeking therapy?
• Has your counselor done his or her own therapy?
• Does your counselor adhere to ethical principles in regard to issues such as boundaries, dual relationships, and confidentiality?
• Does the counselor have postgraduate training?

Warning Signs of Unhealthy Therapy:

• Therapist knowingly or unknowingly gets his or her own psychological needs meet at the expense of focusing on you and your therapy.
• Therapist initiates touch (i.e., hugs) without your consent -- even in a "comradely way" like a hug -- which, unfortunately, Ken Clearwater does

The book: Victims No Longer by Mike Lew  -- in Dunedin library -- call number 362.768 LEW

which, before someone takes part in the group the group leader needs to advise someone against taking part if the prospective member:

• Has not established an appropriate relationship with an individual therapist, preferably of at least six months duration
• Has been in a psychiatric hospital admission for a year before joining the group
• Is the midst of a major life crisis

The 5 Essentials of Effective Trauma Therapy: -- see my previous post on this topic, and this page [LINK]

1. a recognition and acceptance, by the therapist and the client that "You have suffered, but things can change for the better"
2. Skills building
3. a strength orientation -- an understanding of how symptoms have worked in the past as coping skills -- and thus therapy involves a loss, of symptoms, but has benefits as well
4. the recognition by the client that during therapy "I felt safe" -- as the therapy was well structured and explained to the client whenever requested by the client, with the therapist regularly checking on the client's understanding and acceptance of therapy processes; and as a result, therapy was predictable, had known boundaries, goals, structure -- this feeling of safety is essential for change to occur, The therapist needs to say "You tell me how to act", and act in a collaborative, elaborative way.
5. therapy must involve the creation of "workable realities" -- requiring the therapist to know at all times what they're doing; the client is confident that the therapy is evidence-based; and involves the creation of a workable future, in a concrete, defined way, and not just positive thinking

Importantly, I believe, are the elements "I felt safe"  and how this feeling can be destroyed by the presence in the relationship by the therapist displaying any of the "warning signs" listed above; and, if not expressed in these terms, certainly consistent with a "Client-Directed, Outcome-Informed" process, where the client's voice is privileged -- discussed in more detail on this site [LINK]

The client's voice is privileged -- the client's views, and goals, are prioritised, NOT the therapists,

• or if you're in a group NOT the group leader's

An important part of safety, stated plainly in the presentation by Barrett in her 5 Essentials, and in Ken Clearwater's public presentations is that survivors should NOT be pressured into disclosing more than they are comfortable -- this could well involve, initially -- only acknowledging that they have suffered abuse or trauma.  Sure, if THEY choose, they can disclose more, but this is left for the client to decide, and should NOT be an expectation of the therapist, or group leader -- particularly, if it's in a support group, if the group leader has NOT been disclosing of their own story.

The sad facts of the matter are:

• since re-joining the Survivors Group I've been telling the group leader Dave Knox that I wasn't in a position to take on responsibility for the counselling or guidance of others -- that taking care of my own mental health had to be my first priority, after all I was in Dunedin Psychiatric Hospital in April this year, but that I would help out where I could apart from that
• at that same meeting on September 13th he asked me to wait before contacting someone who could act to help me gain access to my clinical records at Ashburn -- perhaps not a "life crisis" but certainly an ongoing and very significant stressor -- that is, he wanted me to NOT seek help in dealing with many people would consider a profoundly important source of stress in my life -- from a counsellor with a record of being successful in providing therapy for survivors -- being an Australian I don't qualify for ACC-funded counselling for sexual abuse issues -- I am not seeing anyone else either
• I told Dave Knox as recently as the last group I attended -- September 13th -- that I was still struggling and so unwilling, and unable, to act in any group role YET DESPITE THIS on September 27th Mr Knox, in my opinion acting totally inappropriately, and certainly contrary to the principles set so long ago by Mike Lew, pressured me to attend the group and act as guide for people attending as potential new members

Hence of the three exclusionary criteria Mike Lew offers for advising against someone's participation in survivor groups, all apply to me, yet for some reason Dave Knox "group leader" pressures me to take part, and tries to make me feel guilty for deciding against taking part in the group -- in fact, not taking part is the SAFE thing for me, and for others, in fact a commendablle decision on my part!!!

Certainly, my voice was NOT privileged -- Dave Knox pressured me to take part -- for his own sake, not others, as I am of the opinion that I would NOT be in a position to act in such a role -- something I have been at pains to tell him, even back when he was breaching the bounds of the group leader - participant boundaries by telling me about his former partner's "sexual activity".

DAVE KNOX RESPONSE TO WHAT HAS BEEN POSTED SO FAR ON THIS SITE:  [LINK]

I am glad this has happened. Perhaps now MSSAT will take steps to remove Mr Knox from his position -- it will clearly be in his own best interests, and in the interests of the public good that this happens.

This site gives grounds for defence against defamation:  [LINK]

Everything I have said about Mr Knox's actions is the truth

I have said these things to try to defend the public against the actions of an inadequately trained, reckless, self-interested "para-professional" -- but it should be noted that Mr Knox has not sought to maintain his professional qualifications (many years ago, in the United States, in psychiatric nursing, he once said), and has not taken part in what any professional organisation in New Zealand would regard as "ongoing professional development"

As I suggested at the start of this post -- if you  wish to "keep safe", which I encourage always -- give MSSAT Dunedin the Big A -- AVOID

This is not to say that other MSSAT branches are also  irresponsible -- though one would have to question funding a branch support group that so flagrantly ignores the very safety guidelines of one of its initial sources of guidance -- Mike Lew's book "Victims No Longer".  In my opinion, MSSAT Waikato seems to have grasped the bull by  the horns in accepting its responsibility for having governance and safety provisions in place -- if only those involved with MSSAT Dunedin could do so -- they have this information freely available to them, yet have sought to go "do their own thing".

YOU? You owe it to yourself to evaluate the evidence, and the published safety guidelines (links to which I have provided in this post, unlike information which is NOT provided to MSSAT Dunedin group members), and draw your own conclusions.

And if you're unhappy with the group? Would you be prepared to try to lodge a complaint, given his style of response -- as all professionals should ASSIST the complaints process.

ME? I have provided the truth, and my opinions, in the interests of the Public Good.

Incidentally, contrary to the claims made by Mr Knox -- I have NEVER considered him, or found him to be, either a friend OR a source of support -- my judgement, however impaired it may have been at times, due to my depression or other disorder, has NEVER been THAT poor. And I told HIM in a text message -- which I kept as a matter of record --  that his actions of September 27th left me with no choice but to have nothing further to do wiith MSSAT Dunedin.

CLEARWATER RESPONSE 01 OCTOBER 2012 -- [LINK]

Unsurprisingly, I am not satisfied with this response.  But I believe it gives further grounds for survivors NOT to have dealings with MSSAT in Dunedin until it has worked out the issues involved in ensuring minimal safety for its clients -- something VERY far removed from the current situation. Tragically.

Last August 26th my friend Wayne killed himself -- in his memory I set up my website and was working on trying to ensure MSSAT offered safe and effective services -- despite Wayne thinking the world of the people from MSSAT he had been associated with in Auckland, he found the services in Dunedin unsatisfactory, and psychologically unsafe. 

Things haven't improved since Wayne's withdrawal from involvement with MSSAT Dunedin over 18 months ago, despite my best efforts.  MSSAT management have not listened -- check the details on the MSSAT -- the "news" is that MSSAT Dunedin was starting up -- "news" from 2009; the contact numbers for MSSAT include Debbie -- who hasn't worked with survivors for over 12 months, and she's leaving for Australia; Kieran -- who left Dunedin to live elsewhere in New Zealand 12 months ago, and Dave Knox -- fresh out of psychiiatric treatment! For MSSAT management, Dunedin is clearly an afterthought.

Wayne found MSSAT Dunedin unsafe, and inappropriate to his needs; he died as a result. Wayne's needs were those of a person abused for years -- physically abused and repeatedly ra[ed by his father -- who had a right to safe and appropriate services from a "male survivors" group. Tragically, he couldn't, and he died alone.

I pray you don't find yourself in Wayne's position, through inadvertently involving yourself with MSSAT Dunedin -- if need be, get treatment over the internet -- see my website for contact details fo the ThisWayUp Clinic -- which research has shown to provide effective and safe services for survivors.
 

Sep 29, 2012       Where do we start recovery?

My website reviews the nature of the disorder frequently associated with childhood experience of repeated or prolonged experiences of  traumatization -- Complex Trauma, in adults, Developmental Trauma Disorder, in children -- [LINK] -- compares Complex Trauma to Posttraumatic Stress Disorder PTSD, and reviews expert guidelines for the treatment of both Complex Trauma and PTSD.  However, there has been some need for identifying "enabling therapy" -- therapy needed to prepare the person for taking part in more intensive, often exposure-based, therapy. This is especially important given that a component difficulty experienced by those with Complex Trauma is emotion dysregulation -- difficulty regulating emotional response to troubling experiences, with such difficulty often resuling in premature attrition, or "dropping out" of therapy. One approach has been emotion regulation therapy -- and a handbook for that is provided via my site. Another approach has been more "cognitive" rather than strictly behaviorally or mindfulness oriented therapy. This cognitive approach has been trialed by Ethy Dorrepaal and her colleagues (2010) --  [LINK]. This study has now been replicated in a multi-site randomized clinical trial (2012) -- [LINK]. 

This is the first randomized controlled trial to test the efficacy of psycho-educational and cognitive behavioural stabilizing group treatment in terms of both PTSD and complex PTSD symptom severity. Seventy-one patients with complex PTSD and severe comorbidity (e.g. 74% axis II comorbidity) were randomly assigned to either a 20-week group treatment in addition to treatment as usual or to treatment as usual only. Primary outcome measures were the Davidson Trauma Scale (DTS) for PTSD and the Structured Interview for Disorders of Extreme Stress (SIDES) for complex PTSD symptoms. Statistical analysis was conducted in the intention-to-treat (ITT) and in the completer sample. Subjects were considered responders when scoring at 20 weeks at least 1 standard deviation below pretest find-ings. Results:The 16% attrition was relatively low. After 20 weeks, the experimental condition (large effect sizes) and control condition (medium effect sizes) both showed significant decreases on the DTS and SIDES, but differences between the conditions were not significant. The secondary responder analysis (ITT) revealed significantly more responders on the DTS (45 vs. 21%), but not on the SIDES (61 vs. 42%). Conclusions: Adding psycho-educational and cognitive behavioural stabilizing group treatment for complex PTSD related to child abuse to treatment as usual showed an equivocal outcome. Patients in both conditions improved substantially during stabilizing treatment, and while significant superiority on change scores was absent, responder analysis suggested clinical meaningfulness of adding group treatment.

Thus, this study serves as a further indication that cognitive and behaioural treatments, as used in this study, by themselves, are not sufficient to equip patients with the more complex problems associated with Complex Trauma Disorder and that, as suggested on the Complex Trauma page on my website, additional interventions are likely required, likely targeting those difficulties identified in individualized, and more comprehensive, assessment. However, given that comprehensive treatment for Complex Trauma is both complex and protracted, at least those interventions used in this study seem to have adequately managed the problem of attrition -- thus the subject of this post -- where do we start recovery -- by identifying those factors associated with attrition and targeting those factors early in treatment.

Sep 29, 2012      New study of emotion regulation in Borderline Personality

Continuing the examination of a central topic in victims of childhood complex traumatization -- emotion dysregulation -- is a new study, which will soon be reviewed, looking at "Dysfunctional affect regulation in Borderline Personality Disorder and Somatoform Disorder" by van Dijke et al (2012) -- [LINK]

In this study, diagnoses of Borderline Personality (BPD) and Somatoform Disorder (SoD) were arrived at by means of clinical interviews; and dysfunctional under- and overregulation of affect and somatoform and psychoform dissociation, childhood trauma-by-primary-caretaker (TPC), PostTraumatic Stress Disorder (PTSD), and Comlex PTSD (CPTSD) were all measured using self reports. While no disorder-specific form of dysfunctional affect regulation was found, inhibitory experiencing states (overregulation of affect and negative psychoform dissociation) were most commonly found in SoD, excitatory experiencing states (underregulation of affect and positive psychoform dissociation) were most commonly found in BPD, and the combination of inhibitory and excitatory experiencing states was found most commonly occurring in comorbid BPD+.SoD. Underregulation of affect was associated with emotional TPC and TPC occurring in developmental epoch, 0-6 years of age. Overregulation of affect was associated with physical TPC. Comorbid BPD+SoD was associated with the most extensive childhood trauma histories and were most likely to meet criteria for CPTSD, followed by BPD, psychiatric comparison (PC), and SoD. The BPD+SoD and BPD reported significantly higher levels of CPTSD than the SoD or PC groups but did not differ from each other except for greater severity of CPTSD somatic symptoms by the BPD+.SoD group. The authors conclude distinguishing inhibitory versus excitatory states of experiencing may help to clarify differences in dissociation and affect dysregulation between and within BPD and SoD patients. Further, these authors state that specific interventions "addressing overregulation in BPD, or underregulation in SoD", should be added to disorder-specific evidence-based treatments.

COMMENT  These authors conclusions and recommendations, as included in their abstract seem in contradiction to their actual results: Whilst in their results section they state that over-regulation of affect was most commonly found in those with Somatoform disorder, and under-regulation of affect was most commonly found in Borderline Personality Disorder -- the obtained results  are consistent with a decades old distinction between "cognitisers" and "somatisers" -- some people express their distress through cognitve phenomena, others through somatic phenomena; and the longstanding heightened emotional lability in those with BPD. What is important, however, apart from clarifying this distinction, is that the results argue for disorder-specific evidence-based treatments. I would argue that rather than going to the step of using disorder-type language, people's actually difficulties with over- or under-regulation of affect be targeted directly.  These conclusions are in agreement with the findings of Dorrepaal et al (2012) reviewed earlier today but the study takes the treatment guidelines further, in the direction suggested in my review of treatment recommendations on my website [LINK]. Complex PTSD is particularly prevalent in BPD and comorbid BPD+.SoD and is differentially associated with both under- and overregulation of affect depending on the type of traumatic exposure.  van Dijke argue that CPTSD warrants further investigation as a potential independent syndrome or as a marker identifying a sub-group of affectively, or both affectively and somatically, dysregulated patients diagnosed with BPD who have childhood trauma histories. In essence, this is merely a re-statement that Complex PTSD is a more "severe" disorder, with a greater mix of symptoms, warranting an independent diagnosis -- something not yet envisioned for DSM5, but clearly something to be expected from van der Kolk's early (2005) description of Developmental Trauma Disorder, in children, and Complex Trauma in adults.

Oct 4, 2012       Suicide Prevention -- Important New Research

In a few of my previous emails I've noted how important it is to ensure that not only should you get suoport in dealing with the enduring effects of childhood trauma, but that the support and treatment you receive needs to be "safe".  Sadly, this "safety" can't be relied on, and many people need to "find their own way" in coping with the demons they carry, including that demon that says "it'll all be over, the self-loathing, the discomfort with others, the real loneliness no one else knows about, if you just end it now" -- uncomfortable thoughts to have, even more uncomfortable if you start listening to them.  Unsurprisingly, many people try to numb the pain associated with such thoughts by using non-prescribed drugs (temember the paper by Kate Scott?  --- [LINK], and the research that shows that nearly all of those admitted, with a previous history of substance abuse, to psychiatric hospitals because they are at risk of killing themselves have histories of childhood abuse or trauma -- [LINK]).

Well, there's some good news. Those who use my website will have already seen me refer to the services available over the internet from the ThisWayUp Clinic at the University of New South Wales.  New research, by Watts et al (2012) [LINK] shows a dramatic reduction in both depression and suicidal thoughts in patients who participated in our in-ternet cognitive behaviour therapy (iCBT ). In this study, almost 300 patients were prescribed the THIS WAY UP Clinic course for depression by their clinician. After completing the six lesson fully automated course, suicidal ideation decreased significantly despite minimal clinical contact and the absence of an intervention focused on suicidal ideation. This reduction in sui-cidal ideation was evident regardless of the sex and age of the patient.

This is the first study to demonstrate this as-sociation in primary care. “Web-based services for people with depression have been cautious about treating people who have suicidal thoughts but this study shows intervention for these people is successful,” says lead author of the study, Professor Gavin Andrews of the Clinical Research Unit for Anxiety and Depression (CRUfAD), St Vincent’s Hospital.

This research is especially exciting, for apart from it being "the first study", it's noteworthy for its brevity, and minimal cost (AUD55 -- research has shown clients improve more if they pay for treatment -- but, as a guide, one-to-one services from a psychologist in Australia, person-to-person, can easily cost over AUD150/hr).

Although more research needs to be done on the applicability to those with Complex Trauma, I have learned in previous professional-to-professional communication with staff at the clinic that up to 50% of their clients have histories of childhood trauma, so these results have exciting implications for survivors visiting this site.

The Clinic can be contacted via email  THIS WAY UP Clinic thiswayupclinic@stvincents.com.au

Oct 5, 2012      Prescription Drugs -- Rational Approach

Not so much new research -- though the importance of the topic really cries out for it! -- is a "functional contextualist" perspective of how the drugs prescribed for mental disorders can be viewed as working.  Brisbane (Australia) Psychiatrist Rob Purssey is presenting a workshop at the next Australian Acceptance and Commitment Therapy conference:  Dr Purssey writes of the workshop -- [LINK]:

Oct 6, 2012     Childhood Psychological Abuse -- Adult Shame

In a recent paper by Harvey, Dorahy et al (2012) [LINK], the effects of childhood psychological maltreatment  were studied using a technique called "Interpretative phenomenological analysis" Specifically, perception of self, others, and relationships were examined in adults with a history.of psychological maltreatment during childhood. Six participants from a low-cost counseling agency completed a semistructured interview. Four superordinate themes emerged: (a) shame-based perception of self, (b) self-protection from emotional pain, (c) limited awareness of others, and (d) shame-based roles in relationships. Stating the obvious in their conclusions they state: "Psychological maltreatment has pervasive and deleterious consequences for self-worth, perception of others, and interpersonal functioning."  Of the research participants, only one was male; however, the results are consistent with an earlier study conducted by Dorahy and colleagues [LINK] available to read here (in pre-publication format) [LINK]

In the latter paper, a "qualitative study" "written" by Martin Dorahy, and Ken Clearwater of New Zealand's Male Survivors of Sexual Abuse Trust, Tthe experiences of shame and guilt in adult males sexually abused as children were examined. Seven participants attending a service for male sexual abuse completed measures of shame, guilt, dissociation, and childhood trauma history and subsequently participated in a focus group. All participants experienced childhood sexual abuse in the "severe" range and showed elevated scores for shame, guilt, and dissociation. Four superordinate themes with associated subordinate themes emerged: (a) self-as-shame (foundations of self-as-shame, fear of exposure, temporary antidote: connection), (b) pervasiveness and power of doubt and denial (from others, from self, consequences of incredulity), (c) uncontrollability (of problems after disclosure, of rage, of intrusions and emotional pain), and (d) dissociation. The emerging "self-as-shame" construct appeared to encapsulate participants' view of themselves.

Both of these studies demonstrate that much can be gained from "small n" studies -- it is rare for studies of male survivors to have more than 10-15 participants. The New Zealand male survivor "movement" has much to owe Martin for his work in this area. I'd like to take this opportunity to thank him for such work, and to congratulate him for his recent "'elevation" to the "rank" of Associate Professor at Otago University. The former study was written by one of Martin's students who has now gone off to other, clinical, work. Of course, Martin, a very talented academic, must be considering his future, even after his recent promotion, and will no doubt go overseas to a position of higher status  and greater research opportunities -- he has already started writing papers with some of the most esteemed trauma researchers in the world. It will be sad to see him depart as New Zealand and the local mens and survivors client groups badly need local, more extensive, research to be done.

This post is motivated by a recent examination of what search phrases people have been using to find my site: childhood physical abuse and current depression being one of them.  I suppose I should write an article reviewing the effects of different types of abuse and different outcomes.  However, two factors stand in the way -- most forms of abuse or adversity occur together -- if you suffer physical abuse, you're also likely to suffer emotional abuse, say, as well as such things as parental chronic illness, parental criminality, exposure to domestic violence, et cetera;  and most studies of the effects of abuse conclude that it is the "severity" of the abuse, and the number of incidents of abuse, that are the primary determining factors for later problems, rather than specific type of abuse -- see Pears, Kim & Fisher (2008) [LINK] for example; and Liu et al (2012) [LINK]. Note, that some specific relationships have been found for anxiety disorders [LINK]. Cougle et al (2010) [LKINK]found, after controlling for depression, other anxiety disorders, and demographic variables, unique relationships between childhood sexual abuse and social anxiety disorder (SAD), panic disorder (PD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD); in contrast, physical abuse was only associated with PTSD and specific phobia (SP). Further, among women, analyses revealed that physical abuse was uniquely associated with PTSD and SP, while sexual abuse was associated with SAD, PD, and PTSD. Among men, both sexual and physical abuse were uniquely associated with SAD and PTSD. Findings provide further evidence of the severe consequences of childhood abuse and help inform etiological accounts of anxiety disorders.

However, in a recent study Gonzalez et al (2012) [LINK] used data from the Ontario Child Health Study, a prospective, population-based study of 3294 children (ages 4-16) enrolled in 1983 and meeting inclusion criteria at follow-up in 2001 (N = 1475; ages 21-35 years) to examine the association between individual (school performance, childhood physical and sexual abuse) and family risk variables (socioeconomic status, parental mental health, medical condition, and functional limitation) with depression only, chronic pain conditions (back pain and headaches) or other CPCs (respiratory, cardiovascular and digestive disorders, and diabetes) and the comorbidity of either CPC category with depression assessed in early adulthood. Controlling for sex and age, childhood history of physical abuse was associated with most outcomes. Parental mental health, childhood functional limitation, childhood history of sexual abuse and family functioning were all related to comorbid depression and chronic pain conditions. Parental mental health was also related to increased risk of other CPCs.  It was  found that the greatest disease risk (comorbid depression and chronic pain conditions) was related to the greatest number of childhood risk factors. Although there was some evidence of specificity, there was overlap in childhood physical abuse predicting almost all outcomes. The researchers argue that efforts targeting the prevention and treatment of childhood maltreatment are critical in order to prevent the long lasting impact of childhood adversity on both mental and physical outcomes in early adulthood. Thus, these results substantially support both the earlier work of such as Pears, Kim, and Fisher; and Liu et al, and the work of Kate Scott from the Dunedin longterm developmental study looking at predictors of chronic physical conditions [LINK].

Oct 7, 2012      Problems in Physical Health Care for Abuse Survivors

Abundant research now exists demonstrating that those who suffered trauma during childhood are at increased risks for suffering not only adult mental disorders, but chronic physical disorders throughout their lives.  On my website I have provided access to my earlier research proposal which briefly reviews some of the history of this research (some of the early work being done by Felletti and colleagues [LINK].  Locally, similar research results have been obtained through the Christchurch longterm developmental study, especially the work of Professor Kate Scott [LINK].

Further aggravating the plight of survivors, however, is the factor that often they have difficulties in a broad range of relationships, including such "instrumental" relationships as relationships with care providers, including providers of medical care. Fortunately, the Canadian Psychiatric Association has been one professional society to address this problem and has developed guidelines for how primary care providers (GPs as we refer to them colloquially)  and such guidelines are available here -- Schachter et al (2009) [LINK].

In recent research article Hovey and colleagues Hovey (2011) [LINK]  article summarizes the findings of a multiphased qualitative study about survivors’ experiences in healthcare settings. The study informed the development of the Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse (Schachter, Stalker, Teram, Lasiuk, & Danilkewich, 2009), which is intended to help healthcare providers from all disciplines understand the effect of child sexual abuse on some survivors’ abilities to access and benefit from health care. This paper discusses what psychotherapists can learn from the healthcare experiences of the male survivors who participated in this project. It also offers practical suggestions for supporting male clients who experience difficulty seeking treatment for physical health concerns.

Another recent study has examined similar ground, this time looking at the effects of attachment difficulties on the quality of therapeutic engagement for women -- Smith et al (2011)  [LINK]  This study study examines how attachment orientation (i.e. anxiety and avoidance) and development of the working alliance are associated with treatment outcomes among depressed women with histories of childhood sexual abuse. Seventy women seeking treatment in a community mental health center who had Major Depressive Disorder and a childhood sexual abuse history were randomized to Interpersonal Psychotherapy or treatment as usual.  It was found that greater attachment avoidance and weaker working alliance were each related to worse depression symptom outcomes; these effects were independent of the presence of comorbid Borderline Personality Disorder and Post-Traumatic Stress Disorder. The effect of avoidant attachment on outcomes was not mediated by the working alliance. Further, working alliance had a stronger effect on depression outcomes in the Interpersonal Psychotherapy group. The authors conclude "understanding the influence of attachment style and the working alliance on treatment outcomes can inform efforts to improve the treatments for depressed women with a history of childhood sexual abuse."  Personally, I have no doubt that the same could be said of male survivors' experiences, as implied in my research proposal, though this has not yet been studied.

Oct 8, 2012      Childhood Adversity and Suicide Risk

In a new book, Benoit Labonte and Gustavo Turecki (2012) [LINK] examine the  epigenetic effects of childhood adversity in the brain and the associated suicide risk as a result.  Their chapter is published in a book titled The Neurobiological Basis of Suicide (further details here [LINK]) and is availale on full at the link I've provided. "epigenetic" means "of or involving the chain of developmental processes from genotype to phenotype after the initial action of the genes" Thus, the  view is essentially biological deterministic -- childhood adversity operates upon a genetically determined biological vulnerability not present in those of a different genotype, or biological heritage. I haven't had a chance yet to review all of the chapters but a number seem to be available online for free at this stage. So, for those not put off by heavy biological jargon and concepts I'd recommend it as a modern introduction to this important concern.

Oct 14, 2012      Childhood Abuse and Lethality of Suicide

Following on from my last post, about understanding the "epigenetic" basis of suicide attempts, a recent paper by Spokas and colleagues at La Salle University [LINK], continues to build evidence which those in Psychiatric Services must take into account in evaluating the  risk of successful suicide.

Spokas and her colleagues explored whether those who impulsively attempt suicide are at lesser or equal risk than those who premeditate suicide. Individuals who made an impulsive attempt expected that their attempts would be less lethal; yet the actual lethality of both groups' attempts was similar. Those who made an impulsive attempt were less depressed and hopeless than those who made a premeditated attempt. Participants who made an impulsive attempt were less likely to report a history of childhood sexual abuse and more likely to be diagnosed with an alcohol use disorder than those who made a premeditated attempt.

These researchers argue that clinicians should not minimize the significance of impulsive attempts, as they are associated with a similar level of lethality as premeditated attempts. Focusing mainly on depression and hopelessness as indicators of suicide risk has the potential to under-identify those who are at risk for making impulsive attempts.  Of equal importance, in my view, is that, following such existing research as that of Dore et al [LINK] clinicians should be especially careful to (a) ask specific questions of patients about history of childhood abuse (b) rate as higher than usual the risk of successful, pre-meditated, suicide in those wiith such histories.  In my view, her research is also significant in that it highlights something I've noticed amongst those who "successfully" complete suicide -- noted in my discussion with fellow colleagues, in the course of clinical practice, and in those friends of mine who have killed themselves -- having an active alcohol (or drug) use disorder is no guarantee that someone's risk of suicide is not high -- many of those with histories of childhood abuse may successfully bring their substance use problems "under control" and then go on to kill themselves. In some ways they seem to accept the lesser world resulting from the damage of their abuse, but their value system does not permit them to accept the life remaining -- an argument for inspiring hope, enabling recovery, and where possible intervening EARLY in the lives of those abused.

Whilst I have written to Professor Spokas requesting a copy of her paper (probably still in a "pre-publication" version), her email autoresponse says she is away -- I'll post her paper if she responds to my request.

Oct 14, 2012      Childhood neglect related to depression and substance use

In an Australian study [LINK], Kylie Bailey, also from the University of Newcastle, where Dore and Mills have done such good work (see previous posts) examining the inter-relationships between childhood trauma, suicidal ideation, and substance use, has examined the role of childhood neglect -- the "dysfunctional parenting" in the title of her paper -- in bringing about trauma, depression, and alcohol use disorders.  Download the study here [LINK]

DESIGN AND METHODS:

Participants (n = 221) seeking treatment for coexisting depressive symptoms and alcohol use problems.  were recruited. Trauma exposure, PTSD symptoms and PTSD were assessed using the Posttraumatic Stress Diagnostic Scale. The Measure of Parenting Style assessed dysfunctional parenting (neglect/over-control/abuse) experienced as a child.

RESULTS:

Most participants experienced trauma (71.6%, n = 159), with more than one-third reaching DSM-IV criteria for current PTSD (38.0%, n = 84). Unique to this study was that there were no gender differences in rates of trauma exposure, number of traumatic events and PTSD. More severe PTSD symptoms and PTSD were associated with: childhood neglect; earlier depression onset; more severe depression and alcohol problems; and lower general functioning. More severe problems with alcohol were related to Intrusion and Avoidance symptoms, while severe alcohol dependence symptoms were related to hyperarousal.

DISCUSSION AND CONCLUSIONS:

PTSD symptoms and PTSD are highly prevalent in those with coexisting depression and alcohol use problems and are associated with a history of childhood neglect and higher levels of comorbidity. Trauma, PTSD symptoms and PTSD should be assessed and addressed among people seeking treatment for coexisting depression and alcohol problems.

Given the prevalence and significance of this problem, I have requested a copy of her paper from Dr Bailey and will be submitting a more detailed commentary when I receive that. -- in a future revision of this post!

Oct 17, 2012       Ya gotta know when to leave the table!

I get inspiring quotes sent on a daily basis and I couldn't help sharing today's -- and adding my own "spin" to it --  prompted by a reminder sent to me by a favourite, though still aspiring, academic author Ann-Laura van Harmelen [LINK]

The quote:

"You have to do what you love to do, not get stuck in that comfort zone of a regular job. Life is not a dress rehearsal. This is it."

Lucinda Bassett

and the commentary (from Trans4Mind author):

"Nothing more stressful and depressing than going to work when it just doesn't cut it anymore... if it doesn't align with your values, doesn't utilize your potential, or you are simply overrun repeating the same old formula. If it doesn't light your fire, look for something better."

van Harmelen's paper warrants repeated reading -- the speaker's use of English as a second language makes grasping some of the important ideas in the paper less easy to take in on first reading -- for example, only much later in the paper is the author's use of the term "expressed" substituted for the word "monitored" -- the former may be more in line with traditional research, while the latter is more consistent with more recent Mindfulness research -- crucial when considering possible therapeutic initiatives -- see this quote on p. 9 "... individuals have more experience in distracting themselves from a personal thought. They may even have developed a network of distracter thoughts and may have used this network in order to distract themselves during the suppression of a personal thought and, subsequently, have diminished intrusions of that thought during the expression phase (Kelly & Kahn, 1994). In line,Salkovskis and Campbell (1994) found higher rates of intrusions of personal thoughts for participants who tried to suppress the thoughts compared to those who only monitored  (expressed) them."  This is certainly what one would predict from a Mindfulness Based Cognitive or ACT approach. 

For me, now, nothing more truly expresses those times in life, when you've had just so much of "the same old crap" that you absolutely have to do "something" about it, like Leave -- how many of us have tried "geographicals" -- leaving where we are in order to "get away" . But,  if all we've done is to physically move from one place to another, while carrying the same emotional baggage with us, how often have we been successful?  As van Harmelen's article indicates, the more you try to force "getting away from it", the more it comes back to haunt you. Looking at the research reviewed, and the clinical models discussed, on my site, one cannot ignore the huge role played by "avoidance" in the onset and maintenance of a lot of psycholgical distress. Certainly van Harmelen's article also supports this conclusion.

In van Harmelen's article, it was found that individuals reporting Severe CEM (versus No Abuse, Low CEM, or Moderate CEM) report more avoidant tendencies for negative emotional experiences. Despite these tendencies, individuals reporting Severe CEM are not more adept in actually suppressing thinking of negative (and positive) autobiographical memories. Furthermore, it was found that when individuals were no longer instructed to suppress thinking about the memory, individuals reporting No Abuse, Low CEM, or Moderate CEM reported fewer intrusions of both positive and negative autobiographical memories when compared to those reporting Severe CEM. Finally, intrusions of negative memories are strongly related with psychiatric distress. Therefore, the present study results may  provide an important avenue to better understand the consequences that emotional child maltreatment might have, as well as suggesting avenues for successful intervention.

The article goes into some detail about possible mechanisms by which the obtained findings could result from a variety of psychological processes. (And the article fails to bring into consideration some results found when looking at such disorders as Borderline Personality, such as the longer than "normal" latency into returning to being settled after aversive emotional arousal). More pressingly,I couldn't help but rhetorically and privately commenting: "That's why we need survivors to be mindful of their experiences AND to take part in research!'  My own life experience has always influenced my perception and interpretation of research in this area, but I must confess even I don't have the answers to questions that arise in this research -- avoidance is part of MY "way of handling" the experiences resulting from my past abuse -- and I try to "over think to (over) protect" myself from intrusive autobiographical memory intrusions -- so much so it's always the body oriented therapy techniques that can make me quake to my core -- a sure sign of lack of "emotional wisdom" -- so here's plug for you to take part in the research surveys hosted on my site, please!

So, we can maintain the emotional distress that we have "always" known, by inadvertently "avoiding" personal issues, or we can try "something different" but in order to be responsive to this "something differrent" we must beware of the "rules" we have set for ourselves. If we adhere to rules we are less open to environmental contingencies, including opportunities for new, growth enhancing, opportunities.  This is not "new research" but it's certainly in line with Mindfulness and ACT approaches -- in fact, there's been a recent brief discussion on the ACT discussion list about "contextual insensitivity" -- insensitvity to environmental contingencies for change when under the control of rules.  So as  ACT practitioners would say "carry lightly" those ways we have mentally constructed our personal stories, how we have come to understand our lives, and the rules we have set up for ourselves to "keep us safe" -- sometimes those rules WILL keep us safe, in the toxic environments we've come from, but straightjacket us and prevent our "movement" in new settings, with new opportunities, with new people.

But some times we really do learn to look for where those new environments, those new opportunities are -- sometimes, coming from toxic relationships early in our lives, we have difficulty investing in new relationships, and sometimes we hang on too long, hoping "this time, it'll be different" -- maybe, be aware of your own issues, aware of other peoples' issues, and different parties' differrent capacities for change.  Sometimes you really have to accept "when the dealing's done" (in the great song by Kenny Rogers), or "when it's time to leave the table".

Oct 20, 2012     Complex disorders, complex treatments

Borderline Personality, Complex Trauma, and Postrraumatic Stress Disorder (PTSD) have numerous features in common. In fact, if the PTSD is a product of childhood trauma, or if the individual with Borderline symptoms suffered Childhood Emotional Abuse, then the resulting patterns of symptoms can be very, very, much alike, calling into question whether or not the disorders can be differentiated at all. One attempt to address these diagnostic difficulties has been the in many ways excellent review by Lewis and Grenyer (2009). [LINK]

Unfortunately, one of the shortcoming of that paper is the limited conceptualization of what constitutes "treatment". I have reviewed experts' recommendations for the treatment of complex trauma on my website [LINK]  Often these treatments are tailored to "disorders" rather than underlying psychological processes.  Acceptance and Commitment Therapy (ACT) has identified some of the psychological processes its researchers / practitioners believe (in some cases have found, particularly in the case of Experiential Avoidance) to be of importance in the onset and maintenance of psychological distress.  I have had several problems being one of the ACT Apostles, such as its adherents discomfort with looking for replication results, and the apparent need to view everything withintheACT theoretical model; in my view needlessly leaving behnd a great degree of other psychological reseearch,  including valuable research looking into other underlying psychological processes, and treatments targeting those underlying processes. One of the most studied has been "emotion regulation",  another has been "distress tolerance" , and Professor Kim Gratz, of the  University of Mississippi, has been one researcher developing and refining treatment programs for psychological processes underlying Borderline Personality Disorder and often co-morbid conditions, such as substance use disorder, and self-harm.  I have provided Prof Gratz treatment manual for emotion regulation difficulties of those who deliberately self-harm  (DSH) [LINK]

A recent paper by Prof Gratz [LINK] has looked at extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality pathology.  The purpose of this study was to further develop  ERGT (Emotion Regulation Group Therapy) by examining its utility across other settings, a more diverse group of patients, a wider range of outcomes, and group leaders other than the principal investigator (Gratz). Twenty-three women received this ERGT in addition to their ongoing treatment in the community. Self-report and interview-based measures of DSH and other self-destructive behaviors, psychiatric symptoms, adaptive functioning (including social and vocational impairment and quality of life), and the proposed mechanisms of change (emotion dysregulation and experiential avoidance) were administered pre- and posttreatment. Results indicate significant changes over time (accompanied by large effect sizes) on all outcome measures except quality of life and self-destructive behaviors (although the latter was a large-sized effect). Further, 55% of participants reported abstinence from DSH during the last two months of the group.

Clearly, mechanisms in addition to difficulties with lack of mindfulness skills, and difficulties with emotion regulation, must be examined if the  significant personal and interpersonal problem of deliberate self-harm is to be fully and successfully overcome and recovery from this problem is to be maintained. Perhaps, more extensive, broader range treatments need to be implemented, at least for those who do not benefit satisfactorily (complete cessation of DSH and improved quality of life) is to be achieved. This is where, I believe, the more comprehensive formulations, and treatment programs, conceptualized by those such as Barrett in Essentials for Effective Trauma Treatment [LINK] can come into their own.

Oct 21, 2012       Distress Tolerance Treatment -- Aiding Substance Users

In my last post I briefly discussed the importance of Emotion Regulation training in the treatment of a number of disorders; among them, Complex Trauma, Borderline Personality Disorder, and in some cases at least, Posttraumatic Stress Disorder borne of childhood interpersonal trauma.  I provided a link to a treatment manual for Emotion Regulation Group Therapy for those with Deliberate Self-Harm (DSH) and today I'd like to say a little more about Deliberate Self-Harm, Substance Use Disorder, and provide a link to a treatment manual for Distress Tolerance.  Firstly, however, I'd like to make sure people are aware of the great variety and quality of resources available at the DBTSelfHelp website  [LINK]  Here's a link to the Distress Tolerance Treatment manual [LINK]

A little studied sign of psychological distress, Deliberate Self-Harm, in those victims of Intimate Partner Violence (IPV) has recently been studied by Jill Messing, Professor of Social Work at Arizona State University [LINK]  Not surprisingly, one of the forms of trrauma, victims of Complex Trauma may experience is witnessing their caregiver (in my case, my mother) being subject to such violence, and experiencing the effects of such violence on their caregiver (this can include, but not necessarily) their caregiver's experience of Posttraumatic Stress Disorder, Depression, Anxiety Disorder(s), or Substance Use Disorder. Naturally, the attachment relationship is put under a great deal of stress, often over a long time, with consequent negative impact on children's capacity to develop satisfactory self-image, self-regulation, and relationships in adult life.

Messing's study was of clients in residential substance use treatment and who were assessed as having low tolerance for psychological distress on laboratory distress tolerance measures were randomized into three conditions: Treatment-As-Usual (TAU), six sessions of Supportive Counseling (SC), or six sessions of the novel distress tolerance treatment, Skills for Improving Distress Intolerance (SIDI). Patients were assessed at baseline for DSM-IV psychiatric diagnoses, DSM-IV substance use disorders, distress tolerance, and depressive symptoms. Patients were again assessed at posttreatment. Therapeutic alliance and treatment expectancies and credibility were also assessed at posttreatment. :Patients who received SIDI (n=28) evidenced significantly greater improvements than SC (n=24) and TAU participants (n=24) on the distress tolerance laboratory measures, even when controlling for changes in negative affect (in the form of depression). Additionally, a higher percentage of patients in SIDI reached clinically significant improvement compared to patients in SC and TAU. This study supports the efficacy of SIDI in improving distress tolerance levels among individuals with substance use disorders currently receiving residential substance use treatment. SIDI appears to be a brief and feasible intervention for use within inpatient substance use facilities. This is an important result but whether it will translate into better longterm substance use outcomes, and other "functional outcomes" remains to be demonstrated. Such other "functional outomes" include persistence in "goal directed activity" -- performance of interpersonal, social and vocational outcomes, say. "Distress Tolerance" is, after all, the ability to persist in goal directed activity when experiencing psychological distress.

Messing's study examined whether potential posttraumatic stress disorder (PTSD) mediated the relationships between different forms of childhood trauma (sexual abuse, physical abuse, violence between caregivers) and intimate partner violence (IPV) victimization (psychological, physical, sexual). Participants were 1,150 female  nurses and nursing personnel. Path analytic findings revealed potential PTSD partially mediated the relationships between child-hood sexual abuse and psychological IPV and childhood sexual abuse and sexual IPV. Potential PTSD did not mediate the rela-tionship between other types of childhood trauma and IPV. This study adds to the literature indicating PTSD as a risk factor for revictimization in the form of adult IPV among women. Messing et al argue that screening for and treatment of PTSD among female child sexual abuse survivors could prevent future IPV victimization.  Perhaps, Distress Tolerance is also one of the types of treatment of potential value to victims of intimate partner violence.

Oct 22, 2012       Trust me -- I'm a doctor, I prescribe drugs

Interesting item recently in magazine "New Statesman" from

Dr Ben Goldacre vs the Association of the British Pharmaceutical Industry

http://www.newstatesman.com/sci-tech/sci-tech/2012/10/dr-ben-goldacre-vs-association-british-pharmaceutical-industry

see more posts on Facebook at Eyes on Pharmaceutico-Industrial Complex Corruption

Oct 22, 2012       Amended post -- "Complex disorders, complex treatments"

I have just received a copy of Kate Iverson's paper An investigation of experiential avoidance, emotion dysregulation, and distress tolerance in young adult outpatients with borderline personality disorder symptoms

and will be discussing it in a future post, and discussing the concept of "covariance" on a new page on my website

Oct 29, 2012       Products of childhood emotional abuse -- adult depression

Previously, on my site, and in these posts, I have spoken about the products of childhood emotional abuse (recall the important studies of van Harmelen such as [LINK]  and [LINK].  In today's post, I wish to provide access to another study, by Castilho and colleagues from Portugal [LINK] -- the Europeans really seem to be leading the race in this important area!

In the Castilho et al study recall of personal feelings of perceived threat and subordination in childhood were investigated in relation to psychopathology. In addition, the researchers also looked at the mediator role of self-criticism in this association. A sample of 193 subjects from the general population completed self-report questionnaires measuring the study variables. The mediator analyses suggested that the impact of submissiveness experiences in childhood on depression and anxiety  is mediated by self-criticism. The findings highlight the route through which the recall of personal feelings of perceived involuntary subordination to parents contributes to depression and anxiety in adulthood. These results "feel right" to me, lookinng back at my own life experiences, and in this regard (being raised by an aunt who resented my presence) I would imagine that children the product of "broken homes", where a "caregiver" becomes responsible for children with whom healthy attachments were not formed earlier in life, would be especially vulnerable to such negative effects.

To qyote the study authors' practitioners' message:

• Although the relation betweenearly experiences of abuse and later psychological problems is now well established, there has been less study on subtler forms of threat and subordinate behaviour in childhood. Given ours and previous findings, therapists should be aware of, and prone to explore, these early experiences.
• Most studies exploring early negative experiencesmainly refer to attachment theory-related constructs (e.g., attachment style). We also highlight the importance of noting rank structure and rank style in the family.
• Self-criticism seems to be a key process in the relation between early aversive experiences of subordin-ation and psychopathology.
• Given the idea that self-reassuring operates through a different affect system, helping people develop inner warmth and compassion for the self may be important to counteract feelings of self-hatred and self-attack.

Unfortunately, whereas my earlier proposed research (see my website for my PhD proposal) was not able to look into possible clinical, defusion-related, de-stigmatization, interventions relevant to this model of causation, we must look  elsewhere for possible clinical interventions;  In this regard, the mindfulness interventions spoken of by Jack Kornfield in his forthcoming presentation for the National Institute for the Clinical Application of Behavioral Medicine will be particularly useful -- stay tuned for my posting of the presentation here [LINK]   The presentation should be posted by midnight, Wednesday, October 31st EDT USA

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.