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Responding to Violence, Suicide, Psychosis and Trauma

From anger management to addiction: online therapies

* Lucy Atkins
* The Guardian, Tuesday 12 May 2009

Eating Disorders

www.b-eat.co.uk offers multimedia support using videos, podcasts, mobile phone browsing, live web chats, message boards, blogs and email or text help, plus one-to-one online support for under 25s from trained advisers. “Authoritative websites are essential as the antidote to pro-anorexia websites,” says Janet Treasure of the Institute of Psychiatry who is also BEAT’s chief medical adviser. The programme allows sufferers to work through their issues and behaviour at their own pace, anonymously, at home. The online CBT approach to bulimia has been tested by a team from the Institute of Psychiatry, and government guidelines suggest that CBT is the best psychological treatment for bulimia. “I didn’t think anyone would answer my message but they did,” says one bulimic woman who used the site. “They were very supportive and I didn’t feel ashamed for the first time ever.”

Sex therapy

therelationshipspecialists.com offers expert help from accredited sex therapists. You fill in a detailed questionnaire about your problem and get a confidential online response within three working days, for £25. Follow-ups with the same therapist cost £35 a pop. The site is run by Paula Hall, a respected sexual psychotherapist accredited with the British Association of Sexual & Relationship Therapy and registered with the UK Council of Psychotherapy. She also works as a family counsellor for Relate. “Lots of people find it difficult to talk about their sexual problems and it’s a lot easier to take that step online,” she says. The virtual approach works best for detailed advice, tips or information on specific sexual problems but, “if it’s very obviously a long-term relationship problem, face-to face sex therapy is usually more appropriate,” says Hall.

Addiction

Former City trader Dan Butcher established the Recovery Network (www.trntv.co.uk) – a social networking site with a difference – after his cocaine addiction landed him in the Priory. The site allows addicts and their families to support each other anonymously. Subscribers also get access to two full-time, trained addiction therapists who run Ask Our Expert sessions, group therapy and live web chats. They can also chat, blog and share information under the watchful eye of the site’s monitors. Real-world friendships spring up and families and friends of addicts feel they are not alone. Monthly subscriptions cost £8.50.

Young people

achance2talk.com is run by the NSPCC and offers counselling, support and information for 12- to 16-year-olds on any troubling issue (abuse, bullying, exams, drugs and self-harm are common ones). Young people can share problems on message boards, or set up a private inbox and email an adviser, who will reply within 24 hours. A confidential “121″ service also means that you can talk online with an adviser (you get the same person if you need to talk again). youthhealthtalk.co.uk is another innovative source of online support where young people can access virtual peer support in the form of interviews with other young people talking about their experiences of anything from teenage cancer to the pressure to perform like a porn star during sex. The site is the brainchild of the DIPEx Research Group at the University of Oxford, so there are plenty of health bigwigs on board, as well as an introduction about the power of storytelling from writer Philip Pullman, and a video clip of Radiohead’s Thom Yorke explaining how to use the site. Both are free of charge.

Anger management

angermanagementonline.com is based in the US and run by psychotherapist and anger management specialist Kathy Garber who treats individuals, corporate clients and those referred by US courts. You buy your self-help programme in time chunks (starting at 10 hours for £33) and sessions will address your anger issues and develop problem-solving and communication skills. There is no direct contact with a therapist though, so this may not work for all. As Phillip Hodson of the British Association of Counselling and Psychotherapy cautions, “Online anger management therapy will not work for everyone – anger can be very difficult and complicated to tackle, so group or one-to one therapy tends to be most effective.”

Filed under: Other Mental Health

Trust ’sorry’ for murders by patients in its care

• Reports criticise Humber mental health trust for failure of care
• Mother of five and elderly woman died in separate incidents

* Sam Jones
* guardian.co.uk, Wednesday 6 May 2009 00.30 BST

A mental health trust has apologised to the family of a pregnant woman who was killed by a paranoid schizophrenic man, and to the relatives of an 82-year-old woman who died at the hands of her mentally ill son.

New reports into both cases have criticised Humber mental health teaching NHS trust for failing to provide better care for the two men.

Tina Stevenson, a 31-year-old mother of five, was on her way home from an ante-natal class in Hull on 5 January 2005 when she passed Benjamin Holiday. The 25-year-old man, who had missed his medication the day before, stabbed Stevenson in the back. Neither she nor her unborn twin boys could be saved.

Holiday admitted manslaughter during his trial in May 2006 and was ordered to be detained indefinitely at a secure mental hospital.

An independent report into his care and treatment published by NHS Yorkshire and Humber concluded he had been “under-treated” by the trust.

Holiday, who had been suffering mental health problems since 2001, spent a fortnight in a secure unit in 2004 but was later discharged and treated in the community. The report admitted that Holiday, whom it referred to as “B”, was a difficult patient to engage with and was skilled at masking his symptoms.

It concluded: “The root cause contributing to B’s continuing severe mental disorder was that of ‘under treatment’. B’s situation and condition could and should have been more assertively managed.”

The chief executive of the Humber trust, David Snowden, apologised to those affected by the case and promised lessons would be learnt. He said his trust “fully accepted the recommendations, which we are taking very seriously”.

The trust also apologised to the family of Ivy Torrie, 82, who was killed by her mentally ill son, Michael, in Pocklington, East Yorkshire, in 2003.

A separate report attributed Michael Torrie’s actions to the “rapid reduction of medication and the way this was managed in the absence of a risk assessment”.

Marjorie Wallace, chief executive of the mental health charity Sane, said that although such events were rare, they did not “come out of the blue”.

“It is not an expensive revolution in care we need but common sense,” she said. “You do not leave an 82-year-old mother alone to care for her mentally ill son whose medication has been radically changed, with no support.

“Nor do you allow someone who may be becoming severely disturbed to dictate their own care and treatment without rigorous assessment of the risk they may pose to themselves or others.

“We have had 15 years of independent inquiries all exposing the same fault lines in the care and treatment of people with serious mental illness.”

Filed under: Other Mental Health, Violence, psychosis , , , ,

Untold stories set to tackle stigma

* Fay Wertheimer
* The Guardian, Wednesday 6 May 2009

Profesor Protasia Torkington, director, Granby Community Mental Health Group, Liverpool.
Protasia Torkington has edited a book by black users of a mental health centre in Liverpool.

A rundown four-storey Georgian terrace in the Toxteth area of central Liverpool, probably built on the back of slave trade money, couldn’t have been the most propitious location for a day centre for black mentally ill adults. But 18 years after it opened its doors, Granby Community Mental Health Group’s drop-in and advocacy project, at the now immaculate Mary Seacole House, offers rights advice, recreational activities, care and a calming environment to 90 people, six days a week.

And to ensure that its legacy endures, seven members’ life stories have been documented in a book called Their Untold Stories, to be launched later this week at a black mental health conference at Liverpool Convention Centre.

Edited by the centre’s co-founder and Hope University emeritus professor Ntombenhle Protasia Khoti Torkington – known as “Pro” for short – the book features clients’ histories in the form of artwork, poetry and prose, which are cathartic and morale-boosting exercises.

Torkington, born in South Africa, qualified as a nurse and midwife and then came to the UK to get specialist paediatric training at Alder Hey Children’s Hospital, where she worked as a ward sister before going back into education.

She says of the book: “I asked people when they first realised they were ill, and then to what they attributed their illness. What unfolded was often rooted in serious sexual violence, long-term physical abuse and racial discrimination. I also encouraged contributors to consider the voluntary and statutory sector services available to them, and to suggest solutions for their own individual needs. Our book concludes by pinpointing key issues that providers should consider when delivering services to mainly black and racial minority communities with mental health needs.”

It logs Mary Seacole House’s success in keeping members out of hospital and endorses the links between a childhood in care and poor mental health. It also supports the request by staff – the nine full-time staff and part-timers are supported by Liverpool primary care trust, the city council and Mersey Care NHS mental health trust – for extra premises to cater for the centre’s 20 daily visitors.

Two weekly art sessions in a small basement, which is also used for IT and snooker, aren’t enough to nurture members’ burgeoning artistry. But this hasn’t deterred 56-year-old Kojo Udarku from attending the centre four days a week since 2005. Following years of discrimination, illness and prison, he found understanding at Mary Seacole House.

“Dictating my story and having my pictures in the book gave me confidence and greater self-trust,” Udarku says. “But those negative feelings from the past never go. My mother, being a white woman in Liverpool with five black kids, had it very hard. And being black in Liverpool in them days was always bad. I was illiterate too, years before they called it dyslexia and gave you help. I experienced prisons, hospitals and sectioning, and I still avoid authority.”

The book presents guidelines for running a non-medical drop-in for mainly black mentally ill adults, as well as displaying their talents – which Torkington hopes will help to tackle the stigma these people face every day.

• Their Untold Stories, edited by Protasia Torkington, can be ordered from Waterstones, price £19.99. maryseacolehouse.com

Filed under: Other Mental Health

Mental health and offending: One man’s prison experience

A new report today by Lord Keith Bradley says offenders with mental health problems are being failed by the criminal justice system. David Smith, who suffers from schizoaffective disorder, explains why prison wasn’t the right place for him

* Mary O’Hara
* guardian.co.uk, Thursday 30 April 2009 16.47 BST

Like many people who run up against the criminal justice system while dealing with a serious mental health condition, David Smith [not his real name] felt that neither the police nor the prison service were equipped to deal with him. Smith has schizoaffective disorder. He manages his condition with fortnightly injections but in early 2008 he missed a series of appointments for medication, and became unwell.

By April his symptoms returned. These included hearing voices. David went to speak to his mother, with whom he had a fraught relationship, about his problems but the encounter turned into a confrontation that frightened her. At 2am the police arrested him on suspicion of common assault. He was locked in police cells for four days.

When he finally went to court they asked for a psychiatric report. The judge recommended that Smith receive hospital treatment but in the absence of a bed in a secure mental health unit Smith was instead sent to Wormwood Scrubs prison and spent a total of four months there.

“I have difficulty remembering my appointments; I never intend to miss any, I just find it difficult to remember when they are,” David says, explaining his state of mind at the time of his arrest. “My regular CPN [community psychiatric nurse] understands this and she gives me a ring the day before to remind me. When she went on leave I got a new CPN. He knew I couldn’t remember my appointments but he wouldn’t ring me with a reminder.

“I must have missed more than one injection,” he concludes. “My friends tell me there’s a pattern when I’m getting unwell. My symptoms came back and when I was at home one day I heard my mum screaming, ‘I’m going to kill myself’. I went to speak to her. I tried to talk to her. Mum just got frightened. I didn’t get anywhere with her so I went home.”

When he was arrested, Smith says, he did his best to explain himself to police officers but what happened was unsettling and frustrating. He recalls: “At the station another police officer asked me exactly the same questions; they didn’t look at any of the notes that had been taken. The policeman was trying to wind me up. I was so pissed off, I just said ‘yeah, whatever’ and sat down. They knew I had a mental illness as my mum phoned the hospital before she phoned the police. I was interviewed and put in a cell for four days. When I went to court the solicitor explained about my condition. One of the first things they said was that they needed a psychiatric report. Then the judge said I should be in hospital but there weren’t any secure beds so I went straight to Scrubs.

“When I got there I was very unwell but I didn’t know I was so I told them I didn’t have a mental illness and they put me on a general prison wing. They did put me in a single cell so I guess they had my [medical] notes. On my first day someone took the TV out of my cell. I thought to myself they’ll take anything, so I sat in my cell for two weeks. For those two weeks I was probably getting worse, more unwell. No one noticed, they [the prison] haven’t got the staff to notice.”

After throwing a chair and wardens intervening because his behaviour became so erratic, Smith was put in the hospital wing of the prison but was soon transferred back into the general prison population.

He reacted by throwing a chair.

“I spent the last two months in the general wing. I was well then. I talked to staff a lot. They were good to me. When I’m well I’m very polite so I was no trouble.”

Smith says that most of all he felt unlistened to, as if what he was going through was misinterpreted and that the prison wasn’t equipped to deal with his problems. He decided to write to a judge to see if he could get his point of view across.

“I wanted the judge to know what happened from my point of view. I felt I hadn’t been heard in court,” he explains. “Everyone talked about me and not to me. I wanted to say I was sorry. My case came up again and the judge said that I had clearly stabilised, I understood what had happened and that I had already served the time I would have done on a guilty plea while waiting for a bed in a secure hospital so I could go.”

Prison life is simply not the right environment for people like himself, Smith believes.

“If you can handle yourself when in prison you’re OK, if not it’s all over,” he says. “I managed but I met guys who came in after me and they tried to commit suicide or burn down their cells. It’s a 23-hour lock down. I spent most of my time pacing in my cell. I can still remember the pattern my pacing took, the same one over and over again. I never want to go back. I’m doing everything in my power not to go back. I’m keeping myself busy.”

Filed under: Other Mental Health, Violence, psychosis , , ,

Adolescents At Risk Of Developing Psychosis Benefit From Early And Network-Oriented Care

Date: 15 May 2009 – 3:00

Family and network oriented, stress-reducing care improves level of overall functioning and mental health in adolescents at risk of developing psychosis, suggests a recent Finnish study. Jorvi Early psychosis Recognition and Intervention (JERI) project at Helsinki University Central Hospital (HUCH), Jorvi Hospital, Finland, is a project with an early intervention team for adolescents at risk of developing first-episode psychosis. As developing psychosis has been suggested to be a result of a combination of acute life stressors and trait-like vulnerability to psychosis, the intervention is based on the idea of multiprofessional, need-adapted, community-, family- and network-oriented, stress-reducing, overall functioning supporting and low-threshold care. The JERI team meets with adolescents at ages 12-20 in their natural surroundings, e.g. at school or at home, together with their parents and community co-worker, who has originally contacted the JERI team because of unclear mental health problems. The aim of the team is to recognize potential risk cases and reduce the stress level by family and network intervention. A follow-up study was performed to test how presented intervention will help adolescents at risk. Data was collected between January 2007 and May 2008. During the intervention, mean scores rose statistically significantly on overall functioning and scores on quality of life, depression, anxiety and pre-psychotic symptoms decreased statistically significantly, showing an improvement in overall functioning and mental health in adolescents at risk of developing first-episode psychosis. Adolescents did not receive other therapy or any antipsychotic medication. “JERI- intervention seems to improve level of overall functioning and support mental health in adolescents at risk of developing first-episode psychosis, even though further study with larger number of subjects, with a proper control group and with a longer follow-up time is needed”, says Dr. Niklas Granö, the leader of the research.

Results are published in the journal Early Intervention in Psychiatry. Reference: Niklas Granö, Marjaana Karjalainen, Jukka Anto, Arja Itkonen,Virve Edlund and Mikko Roine: An intervention to improve level of overall functioning and mental condition of adolescents at high risk of developing first-episode psychosis in Finland. Early Intervention in Psychiatry (2009; 3: 94-98) Source: Niklas Grano, Ph.D. University of Helsinki

Filed under: Other Mental Health, psychosis , , , , ,

7 Year-Old Boy Is Youngest Case Of Suicide Attempt

A new medical report calls for caution following the recent case of a boy who tried to hang himself after watching a hanging depicted in a fictional film. This seems to be the first case of attempted copycat suicide in a child under 10 years old. Exposure to suicidal behaviour in the media has been strongly linked to copycat suicide attempts but never in someone so young. This case warns of the potential danger to young people who are exposed to suicide even when it is fictional, and exposes the previously ignored role of attention deficit and impulsive behavioural traits on suicide.

The case report, published in Cases Journal, describes how a seven year-old Iranian boy was found by his mother, semi-conscious, lying down with a torn band around his neck. It was apparent that the boy had hanged himself after watching a scene in a fictional film in which four soldiers were hanged before being rescued and escaping. The boy was taken to hospital and treated effectively.

There was no history of depression or anxiety in the boy and his medical record was insignificant. The boy’s family history also displayed no suicidal tendencies. However, the boy was diagnosed with attention deficit disorder (”ADHD”) and had a tendency for impulsive behaviour. Although the roles of anxiety and depression in suicide have been well documented, there has been no research into the role of ADHD and impulsivity in such cases, and these should be considered by doctors in future.

Cases Journal publishes case reports from medical professionals from all over the world. As an online journal, it does not have the space constraints of traditional medical journals, and allows the publication of a very broad range of cases. Typically, an important case such as this might never have achieved public exposure due to the high barriers to publication in major journals.

More information about Cases Journal can be found on the website: http://www.casesjournal.com Cases Journal is a peer-reviewed, open access journal. The editor-in-chief is Richard Smith, previously known for his role as editor of the British Medical Journal, and he is supported by an international editorial board. Unlike traditional medical journals, Cases Journal publishes any case report that is understandable, ethical and complete – the perceived interest level, or rarity of the case is not important. The journal’s ethos is that every case is important, just as every patient is important, and we can learn something from every case report.

All case reports published in the journal will be included in the forthcoming Cases Database, which will allow doctors to search all case reports to find those relevant to their practice. As an open access journal, all case reports are free for anyone to download without subscription.

Cases Journal

Filed under: Suicide , , , ,

Man has admitted killing Philip Ellison, the Lancashire Council social care worker

Posted: 24 April 2009 | Community Care
A man has admitted killing Philip Ellison, the Lancashire Council social care worker stabbed to death during a visit to a supported housing project. Robert Searle, 52, was detained indefinitely under the Mental Health Act after pleading guilty to manslaughter at Preston Crown Court today. The Recorder of Preston, Anthony Russell, ordered the detention of Searle at Ashworth Hospital, a high-security institution in Merseyside.

Ellison, a married father of three, was 47 when he was attacked at the supported living scheme in Glebe Road, Preston, in April 2008. Article continues below the advertisement

An internal review into the incident by council officers and Lancashire Care Foundation Trust is expected to be published after Searle is sentenced. Anne Brown, cabinet member for adult and community services at Lancashire Council, said today: “The death of Philip in April last year was an extremely sad and tragic incident that has deeply shocked the county council, the local community and the social care sector immeasurably.

“Although the incident happened almost a year ago we, as an organisation, are still trying to come to terms with the loss of Philip who was a professional social care worker, a valued and respected member of staff and dedicated wholeheartedly to supporting people. “On behalf of the county council, I would like to offer our sympathy to Philip’s wife and sons who have lost a loving husband and father, and to his friends and colleagues – our thoughts are with them, particularly at this very difficult time.”

This week, it emerged that Sunderland charity Mental Health Matters, will be prosecuted under health and safety laws over the death of Ashleigh Ewing. The 22-year-old care worker was stabbed to death in 2006 while visiting a client with mental health problems. Searle was originally charged with murder, but the prosecution accepted a plea of manslaughter on the grounds of diminished responsibility.

Related articles
Independent probe to investigate fatal stabbing of community support worker
Man charged over death of Lancashire community support worker

Filed under: Other Mental Health, Violence , , , , ,

Training Curbs Anger And Aggression In Adolescents With Tourette Syndrome

Article Date: 24 Apr 2009
In the first study to gauge the benefits of anger control training in adolescents with Tourette syndrome (TS), researchers at the Yale Child Study Center have found that cognitive behavioral therapy is helpful for short-term improvement in anger and aggression. The study is reported in the April issue of the Journal of the American Academy of Child and Adolescent Psychiatry. Children and adolescents with TS, a disorder characterized by tics-involuntary, rapid, sudden movements and vocalizations occurring repeatedly in the same way-should also be evaluated for the presence of disruptive behavior problems, according to lead author Denis Sukhodolsky, associate research scientist in the Yale Child Study Center. “In some cases, these disruptive behavior problems can cause more impairment than tics,” he said. “If disruptive behavior is present, cognitive behavioral interventions such as anger control training could be recommended to reduce the levels of aggression.” Sukhodolsky and his team studied 26 children and adolescents with TS (24 boys and two girls between the ages and 11 and 15) with moderate to severe levels of oppositional and defiant behavior. They were randomly assigned to a group that received 10 sessions of anger management or to a control group that received their usual treatment for 10 weeks. When faced with frustrating situations during anger control training, the children role-played appropriate behavior. They were asked to identify and evaluate the consequences of various actions for themselves and others who were involved in hypothetical conflicts. The children were also asked to recall frustrating situations and to problem-solve and role play behavior that would have diffused the problem. They also completed homework to practice “anger coping” skills and share their experiences at the next session. At the end of treatment, parents reported that disruptive behavior decreased by 52 percent in the anger management group, compared with a decrease of 11 percent in the control group. Clinicians who were unaware of the treatment rated 69 percent of the children who completed anger management training as improved compared with 15 percent in the control group. Sukhodolsky said this improvement was well maintained at a three-month follow-up. He and colleagues plan to conduct larger clinical trials to confirm their results. The study is part of a clinical research program directed by Professor Lawrence Scahill to develop and test interventions for children and adolescents. Other authors on the study were Lawrence Vitulano, Deidre H. Carroll, Joseph McGuire, and James Leckman, M.D. Citation: J. Am, Acad. Child Adolesc. Psychiatry, 48: 4 (April, 2009) Links: Denis Sukhodolsky Lawrence Scahill Source YALE

Filed under: Other Mental Health, Violence , , , , ,

Suicide: The Risk Factors

Date: 19 Apr 2009 – 0:00 PDT

http://www.medicalnewstoday.com/articles/146507.php

There are many factors which can increase the risk of suicide – including being male, previous self-harm, psychiatric and/or drug/alcohol disorders, upbringing, exposure to suicide in the media, and smoking. Among employed people, doctors (particularly women), vets, nurses, dentists and farmers are all at increased risk – because they have easy access to drugs or poisons which can be used for suicide. In a Seminar in this week’s edition of The Lancet, Professor Keith Hawton, Centre for Suicide Research, University of Oxford, UK, and Professor Kees van Heeringen, Unit for Suicide Research, University Hospital, Gent, Belgium, discuss these trends. An estimated one million people die from suicide each year, equating to one every 40 seconds – but suspected under-reporting in many countries means this is probably a big under-estimate. Suicide accounts for 1.5% of deaths worldwide and is the tenth leading cause of death. Within Europe, rates are generally higher in northern countries than in southern countries. An effect of latitude on suicide rates was found in Japan, suggesting an influence of the daily amounts of sunshine on suicide. However, countries at about the same latitude, such as the UK and Hungary, can have substantially different rates of suicide. Suicide is a major concern in former Soviet states. More than 30% of suicides worldwide happen in China, where 3.6% of all deaths are by suicide. In developed countries, the male-to-female ratio for suicide is between two and four to one, and this seems to be increasing. Asian countries typically show much lower male-to-female ratios, but these might also be increasing; although in China more women than men die by suicide. Suicide rates are highest in elderly people in most countries, but in the past 50 years rates have risen in young people, particularly men. Suicide rates peak in Spring, especially among men. People born in spring or early summer, particularly women, are at increased risk of suicide. European Americans have higher suicide rates than Hispanic or African Americans, though this gap is narrowing due to increased suicides in young black people. Indigenous populations, eg, Aboriginies in Australia and Native Americans, have higher suicide rates, possibly due to cultural/societal marginalisation and higher levels of alcohol abuse. Suicide rates are, not surprisingly, higher in unemployed than employed people – in part, high rates are associated with mental illness, which is also associated with unemployment. Among people in employment, some occupational groups are at increased risk of suicide. Medical practitioners have a high risk in most countries, but female doctors are generally most at risk. Nurses also have a high risk. In both these professional groups, access to poisons seems to be an important factor in determining the high rates. Among doctors, anaesthetists are particularly at risk, with anaesthetic drugs being used in many suicide deaths. Several other high-risk occupational groups (eg, dentists, pharmacists, veterinary surgeons, and farmers) also have easy access to means for suicide. In general, men tend to choose more violent means for suicide (eg, hanging or shooting) and women less violent methods (eg, self-poisoning). Different populations use differing suicide methods, eg, women in South Asia commonly set fire to themselves to commit suicide. Access to specific methods might be the factor that leads to translation of suicidal thoughts into action. In the USA, firearms are used in most suicides, with risk of their use being highest where guns are kept in households. In rural areas of many developing countries, ingestion of pesticides is the main method of suicide, reflecting toxicity, easy availability, and poor storage. As many as 30% of global suicide deaths may involve ingestion of pesticides. Mental health problems are a major factor in suicide. Some 90% of people who take their own life are believed to have some kind of psychiatric disorder. Depression increases the risk of suicide by 15 to 20 times, and about 4% of people with depression die by suicide. Clinical predictors of suicide in depressed people include previous self-harm, hopelessness, and suicidal tendencies. Around 10-15% of patients with bi-polar disorder die by suicide, with risk at its highest during the early part of the illness. Some 5% of people with schizophrenia also die by suicide. Alcohol misuse, anorexia nervosa, attention deficit hyperactivity disorder, and body dismorphic disorder all increase suicide risk – wit the last example partly explaining why risk increases in women after breast enlargement surgery. Physical health also plays its part, but with some strange findings. Surprisingly, while people with higher-body mass index are at increased risk of depression, they have a lower risk of suicide (15% decrease in suicide risk for each 5 kg / m2 increase in body-mass index). The reasons for this are unknown. Cancer, particularly of the head and neck, HIV/AIDS, multiple sclerosis, epilepsy, and a range of other conditions also increase suicide risk. Other factors that can increase suicide risk include physical and sexual abuse throughout childhood, population-wide events such as natural disasters and deaths of celebrities. Suicide rates rose by 17%* following the death of Diana, Princess of Wales in 1997, with the increase being more pronounced in women in her age group. War decreases suicide risk, perhaps due to the social cohesion it can create in communities. People bereaved by suicide are themselves at increased risk, and clusters of suicides can happen in communities or through internet contact. The authors add: “A substantial body of evidence indicates that certain types of media reporting and portrayal of suicidal behaviour can influence suicide and self-harm in the general population.” Post-mortems of suicide deaths have shown changes to the central neurotransmission functions, for example to the serotonin (mood-improving hormone) system. Low cholesterol concentrations are associated with increased suicide risk, but the risk is higher when low cholesterol has been achieved through diet rather than statins. The authors speculate this could be because people who diet are more at risk of mental health problems, but say there is little evidence to back this. Family history of suicide at least doubles the risk of suicide for girls and women. Suicide occurs in tandem more in identical twins compared with non-identical twins. While evidence is limited, high levels of lifetime aggression are associated with a high risk of suicide, while impulsivity also increases the risk. Suicide rates rise throughout teenage years, especially in boys, and family ‘transmission’ of suicide risk occurs, especially on the maternal side. Prevention of suicide is a difficult concept due to high number of factors involved, but strategies can target high risk groups or aim to reduce the risk to the population as a whole. Each person with depression should be screened for suicide risk by specifically asking about suicidal thoughts and plans. The authors say: “In cases of high or imminent suicide risk, immediate action is needed, including vigilance and supervision of patients, perhaps through hospitalisation, removal of potential methods of suicide, and initiation of vigorous treatment of associated psychiatric disorder.” They also discuss a recent meta-analysis of randomised trials which suggested that the risk of death and suicide in people with mood disorders was reduced by 60% in those taking lithium. Removal of means used for suicide is important in management of individuals, and modification of general access to dangerous means can also be effective in suicide prevention at the population level. The authors say: “One striking example of the effect of availability of a common means of suicide was the large reduction in suicides following the change of the UK gas supply from toxic coal gas, the most common method used for suicide during the early 1960s, to non-toxic North Sea gas.” Introduction of safety barriers on bridges and increased gun control can also decrease the risk of suicide, as can safer storage of pesticides and poisons, especially in rural areas of developing nations. School programmes to improve mental wellbeing, and more stringent control of media reporting of suicide could also have a preventive effect. The authors conclude: “Future research must focus on the development and assessment of empirically based suicide-prevention and treatment protocols. The challenges of preventing suicide in developing countries need particular attention, because most research comes from developed countries, but most deaths by suicides happen in developing countries. “Suicide” Prof Keith Hawton DSc, Prof Kees van Heeringen PhD The Lancet, Volume 373, Issue 9672, Pages 1372 – 1381, 18 April 2009 Source The Lancet

Filed under: Other Mental Health, Suicide , , ,

Step-fathers who Kill

Lurking in the shadows

Posted: 09 April 2009 | Community Care Magazine http://www.communitycare.co.uk/Articles/2009/04/09/111233/lurking-in-the-shadows.html

Maria Colwell. Jasmine Beckford. Heidi Koseda. Kimberley Carlile. Leanne White. Lauren Creed. Baby P. These names don’t resonate only with social workers; as some of the UK’s most notorious child deaths they conjure up grim details that are etched on the nation’s collective memory.

And they have something else in common: they all died at their stepfather’s hands. In many cases their mothers received prison sentences for offences ranging from neglect to assault or manslaughter.

Sadly, these are just a few names on the deathly roll call that stretches back to 1973 of young children killed by their stepfather or their mother’s boyfriend.

No matter how good our protective or preventive measures, there will always be parents who will harm or even kill their children. Whether the killer is their biological father or their stepfather may not seem that relevant when it comes to informing preventive policies, but research suggests otherwise.

In 1988, US data showed that children aged up to two are at about 100 times greater risk of being killed by their stepfather than their biological father. Psychologists call this the Cinderella effect. The research went on to look at British data, concluding that it indicated “considerable excess risk at the hands of stepfathers”.

With the rates of remarriage, divorce and cohabitation steadily increasing, giving rise to more stepfamilies, this is a disturbing thought. According to the Office of National Statistics, in 2006 84% of stepfamilies consisted of a stepfather and biological mother living with children from her previous relationship.

Research suggests that whereas genetic fathers often kill their children “more in sorrow than in anger”, out of perceived necessity and/or as part of a suicide, homicides committed by stepfathers tend to be more rage driven, impulsive acts motivated by hostility towards the child and characterised by violently beating or shaking them.

Despite this evidence, some researchers believe that minimal attention has been given to stepfathers – or mothers’ boyfriends – as the perpetrators of these crimes and the reasons behind them.

David Finkelhor, director of the Crimes Against Children Research Center in the US, says: “Sociobiologists point out that these are men who have no genetic stake in this child and see them as competition for attention and time, and their own offspring. Among other primates it’s not unknown for a new alpha male to kill the children of the dominant male when he comes into a group.”

But Finkelhor believes the reasons are simpler than that. “That has some reality to it, but I think it operates through more familiar psychological mechanisms; that these aren’t men who feel a natural affinity or protectiveness about the children of the women they are involved with. These are not men who are nurturing.”

Anger management

This squares with the fact that a child’s inconsolable crying is one of the main triggers for these homicides. “Frequently the dynamics of these cases are common,” says Finkelhor. “The woman leaves the child with the boyfriend or stepfather and when the child starts crying, he doesn’t have the nurturing skills to handle this in a calm way and then hits, throws, or smothers them because he wants them to shut up.

“They are not all of one sort, but a high proportion [in these cases] are violent, abuse their partners, and tend to have an anger management problem.”

Gathering any deeper psychological profile of these men is hampered by the fact that we know so little about them, and what we do know is usually learned after a child has been killed – which isn’t helped by serious case reviews that mostly focus on the pathology of the mother.

This reflects the continuing failure of agencies to engage properly with men, says David Derbyshire, Action for Children’s head of performance improvement and consultancy, and author of several serious case reviews.

“We probably don’t know a lot because too many times we come across cases where there is no involvement with men. Then there is an incident where the child is injured or dies, the serious case review takes place and we see the intervention is often only all with the woman and the man is not known about, or if he is, there’s no contact.

“If you don’t engage with the man but he is there everyday then the work we are doing is going to have a limited impact.”

Before we can even reach a position where men are properly involved, social workers need to recognise their importance to the whole familial picture and approach them with an open mind, which appears to happen too infrequently.

Research for a book he was writing on gender and child protection led says Jonathan Scourfield, senior lecturer at Cardiff University’s school of social sciences, to interview social workers about how they worked, or didn’t work, with men. He found primarily pejorative views.

“Men were seen as a threat, as no use, as irrelevant and absent – and there was a whole host of reasons given for not engaging with them.”

The dominant theme was of men as a threat, not surprisingly given the kinds of problems that caused referrals to be made to the team. But what worried Scourfield was the number of men that social workers didn’t pick up on. “Often there’s a boyfriend, the mother doesn’t mention it, but he’s hovering in the background, half noticed.”

Even if he is seen or known about, it’s all too common for no real attempt to be made to engage him. “The social work culture is an important part of that, but there’s a huge issue with the actual behaviour of these men. We are talking about men who are very difficult to work with and that needs to be acknowledged,” Scourfield adds.

This leads to questions of how a social worker can confidently decide whether to engage with the individual, or whether they are so dangerous they should be removed from the child’s life. It’s a dilemma that troubles Brid Featherstone, professor of social work and social policy at Bradford University: “We haven’t equipped social workers to work with these men. We haven’t got skills in assessing men generally, so we don’t even get as far as deciding that this man shouldn’t be in the family home.

“There is a problematic absence of an evidence base in the UK about working with men – either those who are a resource for children or a risk. Half the time we don’t know who is in a family. We don’t even record birthfathers if they are not there so how are we going to find others floating around? We tend to rely on the mother but it can be hard to establish living arrangements, as we can see in the Baby P case.”

The need for evidence

Jack Kennedy understands these difficulties. As a consultant in clinical and forensic psychology he compiles psychological reports for courts and parole boards and has worked on some of the most well-known child death cases. “Social workers have a very difficult job because they need evidence to act,” he says. “But it’s very difficult to anticipate or intervene unless there are overt indicators of risk or harm. Society almost expects [social workers] to be a ministry of pre-crime and intervene before these events happen, but to go in and remove a child on a suspicion won’t hold up in court.”

Other than obvious danger signs such as known domestic violence or injuries on a child, Kennedy suggests that where social services are involved with a family they need to be aware of mothers developing new relationships and people visiting the home. “Not least because it can be destabilising for the child having different people coming into the home. And also because they can assist a mother in actively risk managing all the time. But there is a thin line between policing and social care.”

However, any information social workers pull together often comes from the mother and therefore relies on her being honest. This is unlikely to happen if she is witness to her partner abusing her child but feels powerless to do anything about it.

While most of us would find this thought process hard to fathom, the issues behind this “collusion” can be complicated. The personality of these women can form part of the equation. Research into these deaths shows that many women lived in fear of their partners and that violence and abuse against a partner and child often coexisted.

These women can be depressed, overwhelmed or so distracted by their own difficulties that they don’t feel capable of doing anything. Women who are desperate to keep a partner will placate them, or those who are so intimidated by a partner won’t stand up to them.

“These are usually highly vulnerable women who have a confused understanding of relationships,” says Kennedy. “Their backgrounds are characterised by abuse and they are highly dependent on being in a relationship even if it’s dysfunctional because that provides them with the security they are looking for. Many women prize the man they have highly because they believe themselves to be loved in some way. Love and affection become more important to them than the needs of the child.

“They are not resilient enough to say ‘that is wrong, this is over,’ because they think they will not get anyone else. This is not about excusing their behaviour, it’s about helping us understand more about what sort of situation an individual may be in.”

Featherstone goes further, saying there are women who are terrified, and other more complex women who don’t acknowledge their ambivalence to their child. “We are hamstrung by the assumption that all mothers love their children or, if they don’t, they can be helped to. But we have to acknowledge maternal ambivalence. Hate can become the more dominant feeling. I have worked with a small number of women who were sadistic themselves. While you are not going to get lots of these women, sometimes you have to think the unthinkable.”

In 2007-8 there were 45 homicides of children aged up to four, according to the Home Office. But these figures don’t include death by neglect or cases which, although were not classified as murder, were not accidents either. Some analysts in the US believe that, there, the actual figure for child homicides may be double the official one because they can resemble deaths resulting from accidents or other causes; for example, a child who has been thrown or intentionally dropped will have similar injuries to those of one who died after an accidental fall.

The so-called Cinderella effect has no fairytale solution. Evidence of the prevalence of deaths caused by stepfathers is there, though the connection is not always made. But we owe it to the memories of all those children from Maria Colwell to Baby P to make sure we know who is present in a child’s life and whether they are a resource or a risk, so we can prevent as many children as possible from ending up on the same list.

RESOURCES

* Crimes Against Children Research Center

* Men who Murder Children Inside and Outside the Family, K Cavanagh, R Dobash.

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