Impact News

Responding to Violence, Suicide, Psychosis and Trauma

A psychopath can go far

From , February 9, 2009

I must have been seven or eight. A circle of older boys had gathered in a corner of the park behind the war memorial, laughing and cursing. At the centre of the circle there was a brick and, lashed to the brick, a frog. Inside the frog’s mouth was stuffed a firework. I turned and ran as Vince, the unsmiling leader of the gang, was lighting the touch paper. You kept your distance from Vince. He was a psychopathic bully who took the pennies from your pocket and smacked your ears with catapult elastic. He enjoyed smashing windows. These days he would probably bear the label “conduct disorder”, no doubt graduating to “antisocial personality disorder” (APD) at the qualifying age of 18. But to my juvenile eyes he was evil personified.

The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on the treatment, management and prevention of APD, which is found in 3 per cent of men and 1 per cent of women. It’s an admirable document, setting out a framework for care across mental health services, social care and the criminal justice system. But between the lines of constructive concern and optimistic practical advice one can’t help but read the chill signs of hopelessness. APD may be a problem without a solution. Characterised by exploitative and aggressive behaviour, reckless impulsivity and deceitfulness, and strongly associated with criminality (evident in around 50 per cent of the prison population), the condition is inherently difficult for clinicians to deal with. The causes are complex and poorly understood and it is not easily remediable through psychotherapy or drugs.

APD is a personality disorder – an enduring and troublesome pattern of experience and behaviour that deviates markedly from the expectations of the individual’s culture. The NICE guidelines set out some important principles of care. People with APD should not be excluded from health and social care services on grounds of being “difficult”. On the contrary, efforts should be made to engage with, and motivate, such people. Treatment interventions are more likely to be effective if relationships are optimistic and trusting as opposed to punitive. The need to identify children at risk of developing conduct disorder is also rightly emphasised.

I have no idea what became of Vince but, if they don’t land you in jail, certain psychopathic traits (superficial charm, grandiosity, pathological lying, etc.) can come in handy for a career in business, say, or politics. At least one young boy who liked to blow up frogs with firecrackers grew up to be President of the United States.

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Filed under: Other Mental Health, Violence

What makes an arsonist?

Fires don’t come any more dramatic than those that have blazed across the Australian bush this week. The bushfires, helped by record summer temperatures and nourished to deadly effect by gales, have left a trail of deaths, injuries and homelessness in their fast-moving wake. Their ferocity has horrified all who have come into contact with them.Well, nearly all. Perhaps one or more individuals will have been watching the flames excitedly and gazing upon their own handiwork. Two people have already been charged with arson, and more arrests are expected.

Why would anybody start a fire intentionally, let alone one that results in so many deaths? In the case of the Australian bushfires we don’t yet know, but when those responsible put a flame to the tinder, they, like all arsonists, had their motivations. It may have been mindless vandalism or an act of bravado to impress delinquent friends; a quest to stir up a little excitement, or a plot to gain an insurance payout. The motive may even have been sexual – for some pyromaniacs (compulsive fire-starters who have a psychiatric condition that leaves them with an uncontrollable urge to start fires), nothing holds more erotic charge than a lit match. And there are remarkably few treatments or interventions for serial offenders, although Rampton Hospital in Nottinghamshire runs a treatment programme for the most dangerous arsonists.

An obsession with fire can start very young, according to Dr Louise Almond, a psychologist at Liverpool University who has studied the motivations of arsonists in Britain. “Many children between the ages of 5 and 10 are fascinated with fire and want to play with matches,” she says. “This is a normal fascination but it can grow into a curiosity-driven behaviour with their own property, so they may set fire to their toys.” In some cases the consequences are tragic – a handful of children are killed each year in this way. (Some scientists have speculated that a fondness for “fire-play” is a natural consequence of our evolutionary history, and that pyromania happens when the brain circuits that allow us to deal with fire go wrong.)

Of the children – mostly boys – who indulge their curiosity about fire, some 40 per cent persist with the behaviour into their teens; they tend to be children with higher levels of behavioural and psychological problems. But not all arsonists start their behaviour in childhood. Some come to it later in life.

People who start fires deliberately fall into distinct categories. Some are simply hooligans, and their crimes come under the heading of “vandalism”. They are not necessarily mentally disturbed but are prone to antisocial behaviour, such as truanting. For them, starting a fire may achieve the same pointless end as smashing a window.Their targets – often schools – are opportunistic, and the fire might be started by a youth keen to show off to his friends. According to The Burning Issue, a 2002 report on arson written by academics for the Government, to which Dr Almond contributed, this sort of incident accounts for about a third of deliberate fires and is more common in socially deprived areas.

Another category is the “malicious firesetter”, who uses fire as a weapon to get back at someone or something. It is not unheard-of for disgruntled former employees to wreak revenge on their bosses in this way, or for a divorced man to set fire to his ex-wife’s house. It has been mooted that someone with a grievance against the Australian Government might be motivated to start a bushfire, because it devastates Government-owned land.

Then there is the “criminal firesetter”, who lights the petrol-doused rag for criminal reasons – perhaps to cover up another crime, such as murder or robbery. Joyriders often burn out the cars they steal, to cover their tracks. Criminal firesetters may simply want an insurance payout for an old car or a business that is about to go into liquidation. Dr Almond says: “We know there are professional fire-setters out there, who will use very sophisticated techniques to burn down, say, a failing business. They use lots of accelerants and start fires in multiple places. But they are not easy to track down – it’s like trying to find a hitman.” She notes that there has been a rise in vehicle arson as the value of scrap metal has plummeted – now more people are setting fire to their cars to claim on the insurance.

But perhaps the most perplexing category is the person who starts a fire for reasons of “emotional expression” (also known as psychological fire-setting). This category, which accounts for just over a quarter of fires started deliberately, encompasses pyromaniacs, who find a kind of release, sometimes sexual, in starting fires (and sometimes achieve gratification through watching the fire brigade dealing with their activities). Pyromania is a psychiatric condition that can be treated with drugs but, as with other mental health problems, the results of drug treatment vary from patient to patient.

Pyromaniacs represent only a small proportion of emotionally motivated fire-starters. “Some people use fire as a way of communicating their pain, or as a cry for attention,” Dr Almond says.

Among those in the “emotional” classification is the would-be hero who starts the fire, then rushes to report it and/or deal with it. Firefighters and security guards have been known to do this. Fleur Lombard, the first female firefighter to die during peacetime, was a victim of this type of arson in 1996. Martin Cody, a security guard, spent a troubled childhood dreaming of becoming a hero, and started a fire in a Bristol supermarket on his first day at work. He even helped the deputy manager to escape it, by smashing a window. Cody phoned a friend to boast about what he had done. Unfortunately, Lombard did not survive the fire and Cody was jailed for manslaughter and arson.

Meanwhile, the tragedy in Australia continues to unfold. In 2004, the Australian Institute of Criminology recognised that bushfires started deliberately were a specific form of arson that needed closer investigation. It reported that “in most cases it is likely that adults who set bushfires do so for excitement or thrills, or the need for attention”.

The report also raised the disturbing prospect that some fire-setters, seeing bushfires splashed all over the media, could be tempted to add their own efforts, whether they were thrill-seekers or motivated by the prospect of being hailed a hero: “The response of fire services may be rapid and on a large scale, and is likely to be heightened by a sense of urgency which adds to the overall experience.

“The existence of other fires and community concern will increase the likelihood of extensive media coverage. This, in turn, will increase the potential for community recognition and the according of ‘hero’ status to those for whom this is a motivating factor.”

But perhaps we can only truly understand by listening to the words of an emotional fire-starter. Sarah Wheaton – a pseudonym – once wrote of her life as a pyromaniac for the American Psychiatric Association.

She wrote that she “revel(s) in the notoriety of the unknown fire-setter”, even if it was someone else who dropped the match: “I watch the local news broadcasts for fires that have been set each day and read the local newspapers in search of articles dealing with suspicious fires. I read literature about fires, fire-setters, pyromania, pyromaniacs, arson and arsonists. I contact government agencies about fire information and keep up-to-date on the arson detection methods that investigators use. I watch movies and listen to music about fires. My dreams are about fires that I have set, want to set or wish I had set…

“A fire not my own offers excitement and some tension relief. However, any fire set by someone else is one I wish I had set. The knowledge that there is another fire-setter in the area may spark feelings of competition or envy in me and increase my desire to set bigger and better fires.”

That must be the last thing that those in the Australian bush around Melbourne want to hear.

Terrible legacy of the fire-starters

A fire at an East London warehouse (above) in May 2004 destroyed more than £50million of modern British art, including 16 Damien Hirst paintings and Tracy Emin’s £40,000 tent. Another part of the warehouse had been burgled and the thieves were thought to have started the fire to cover their tracks.

A 15-year-old boy caused £1.5 million in damage to Manor Comprehensive School in Mansfield, Nottinghamshire, when he set fire to it. The teenager told police that he hated school and wanted to burn it down so he wouldn’t have to go. He was given three years’ detention.

An arson attack on an Iranian cinema in 1978 claimed more than 400 lives. The country’s Intelligence Service was implicated in causing the fire at the Cinema Rex, but the Shah of Iran at the time, Mohammad Reza, said that Islamic militants were responsible.

In June 2000 a homeless fruit-picker set fire to the Palace Backpackers Hostel in Childers, Queensland, Australia, while dozens of teenagers slept inside. Fifteen backpackers were killed, seven of them British. Robert Long, who had a history of mental illness, was sentenced to a minimum of 20 years for the attack.

Rogue property developers were accused of starting forest fires that swept across Greece in summer 2007. More than 60 people died in the blazes, which were fanned by strong winds. It was claimed that arsonists had been paid by developers who wanted to get round planning laws.

Chloe Lambert

Filed under: Other Mental Health, Uncategorized, Violence

Attacks on Mental Health Nurses

13th February, BBC News

More than half of nurses on mental health wards have been physically attacked, a survey suggests. Nurses working with older people are the most likely to be assaulted, the joint Healthcare Commission and Royal College of Psychiatrists report said.
The study of 69 NHS trusts and private hospitals in England and Wales said patients had also been attacked and more had to be done to stop violence.
Health bosses said the situation was taken “very seriously”. And it comes as the Health Service Journal reports that mental health staff are still waiting for violence training promised following the death of schizophrenia patient David Bennett in 1998.

He died after being restrained by staff at the Norvic Clinic in Norwich.

The audit covered eight in 10 of the organisations providing in-patient care for the 30,000 mental health patients in England and Wales.

Nurses, doctors, visitors and patients were all asked about whether they had suffered attacks, threats and what could be done about it.

Some 46% of nurses in mental health wards for working age patients said they had been assaulted.

For those working in older people’s wards this rose to 64%.

Most of these attacks happened in those wards caring for people with “organic” conditions such as dementia rather than “functional” problems such as depression and schizophrenia.

Nurses reported they had suffered fractures, dislocations and black eyes.

Patients were also revealed to be under threat with a fifth of working age patients being attacked. For older patients, the figure dropped to 6%.

A fifth of clinical staff working with older people said they were attacked, with the figure dropping to 13% of those working with working age people.

Violence

The report said improvements were needed to reduce levels of violence, which many of those quizzed said was getting worse.

In particular, it suggested staffing levels should be increased, training improved and patients be given more activities.

However, it did acknowledge that in recent years attempts had been made by providing staff with alarms and improving the reporting of incidents.

Anna Walker, chief executive of the Healthcare Commission, said: “The audit reveals worrying levels of violence against staff in mental health units.”
And Dr Peter Carter, general secretary of the Royal College of Nursing, added: “These levels of violence are deeply serious and unacceptable, whatever the area of care.

“The RCN commends nurses for maintaining the same dignified commitment to patient care, even under such constant threat.”

Steve Shrubb, the director of the NHS Confederation’s Mental Health Network, which represents managers, said the violence was “unacceptable”.

“Mental health service providers take this very seriously and the way these incidents are dealt with has improved.”

Filed under: Violence

Knife Crime – Free Resources

It does not have to happen

The Home Office recently launched a website to support people and organisations working to tackle youth knife crime in their area. The website provides tools, materials and a stakeholder and a young people’s toolkit. Toolkits are free of charge and can be ordered by ringing 0845 600 4171 or, if you prefer, you can download them from the website. You can also sign up online to the It Doesn’t Have to Happen monthly e-newsletter, which brings you all the latest news on the national youth anti-knife crime campaign It Doesn’t Have to Happen. If you have any queries please contact info@itdoesnthavetohappen.co.uk

Filed under: Violence, ,

Women’s mental health deteriorates as one in five experience common disorders

An NHS report has found a significant increase in the number of women suffering from depression, anxiety and suicidal thoughts

* Ali Ahmad
* guardian.co.uk, Wednesday 28 January 2009 15.31 GMT

Women’s mental health is deteriorating according to an NHS report that has found that more than one in five of the adult female population experiences depression, anxiety or suicidal thoughts.

The report found the proportion of women aged 16-64 with common mental disorders (CMDs) increased from 19.1% in 1993 to 21.5% in 2007, whereas the rate in men did not alter significantly.

The largest increase in CMD rates, up 20% between 1993 and 2007, was among women aged 45-64. The proportion of women aged 16-74 reporting suicidal thoughts also increased from 4.2% in 2000 to 5.5% in 2007.

Based on the results of a study of over 7,000 households carried out by the National Centre for Social Research together with researchers at the University of Leicester, the Adult Psychiatric Morbidity Survey is the latest in a series of surveys conducted at roughly seven-year intervals, with previous surveys carried out by the Office for National Statistics in 1993 and 2000.

Its key findings have already sparked debate among experts and mental health charities about the relationship between gender and mental illness, focusing on likely explanations of these trends.

A spokeswoman for the mental health charity Mind said: “One of the reasons that might explain the increase of common mental health problems in middle-aged women (45-64 years) could be the heavy burden they face as primary carers. Having children later in life means today’s women in their 40s and 50s face numerous responsibilities such as caring for elderly relatives, looking after young children or teenagers, and managing a full-time career. Wearing all these different hats can be very stressful and leaves little time for women to concentrate on their own mental wellbeing.”

Emma Seymour, service manager at Threshold, a Brighton-based organisation, which runs a mental health service for women says she “is not surprised by the figures”. Seymour speculates that the reasons for the deterioration in women’s mental health could include increased financial pressures, especially for lone parents, whose circumstances may well harshen in the current economic squeeze. For those who cannot afford adequate childcare provision, she points out, accessing mental health support services can be difficult, “with negative consequences for wellbeing”.

The report also found that age was a significant factor in determining the way CMDs are experienced by individuals. For instance, one in five women aged 16-24 screened positive for an eating disorder, but the figure dropped to just one in 100 among women aged 75 and over. And while men were more likely to gamble than women, the highest rate of gambling was observed in men aged 25-34 (75.4%), whereas for women it was 55-64 (69.5%).

Filed under: Other Mental Health, ,

Suicide is rare among young children, but they’re not immune

– February 06, 2009

Feb. 6–The death of a 10-year-old boy found hanging this week in an Evanston school bathroom demonstrates that even the youngest aren’t immune from taking their lives, mental health experts said Thursday.

Though rare, suicide is the sixth-leading cause of death among children ages 5 to 14. Among ages 15 to 24, it’s the third leading cause, said Dr. Louis Kraus, chief of child and adolescent psychiatry at Rush University Medical Center.

Most children by age 8 understand the permanence of death but do not appreciate the consequences of their actions, he said.

“The majority of kids that kill themselves don’t intend to actually kill themselves,” Kraus said. “It’s something impulsive. It’s out of anger or frustration.”

What Aquan Lewis intended when he walked into the Oakton Elementary School bathroom Tuesday remains unknown.

The 5th grader, described as a happy child who loved sports and enjoyed school, reportedly told a teacher who scolded him that he would harm himself the same day his body was discovered hanging from the hook of a stall door, according to sources familiar with the case. A source said Aquan had psychiatric problems. His mom, Angel Marshall, said her son never harmed himself or acted suicidal.

State Rep. Mary Flowers (D-Chicago) plans to introduce a bill next week that would mandate suicide prevention training for all educators statewide. Current law requires training in secondary schools but not for elementaries.

Evanston-Skokie School District 65 teachers get annual training in abuse, neglect and suicide prevention, a spokeswoman said.

Author Paul Raeburn, who has written extensively on childhood psychiatric disorders, contends suicide is almost always a symptom of mental illness.

“Adults will ask ‘why?’ The answer in almost all cases is ‘because he was sick,’ ” Raeburn said.

Tribune reporters Susan Kuczka and Ofelia Casillas contributed.

tmalone@tribune.com

brubin@tribune.com

Filed under: Suicide

Army suicides at record high, passing civilians

– January 29, 2009

WASHINGTON – Stressed by war and long overseas tours, U.S. soldiers killed themselves last year at the highest rate on record, the toll rising for a fourth straight year and even surpassing the suicide rate among comparable civilians. Army leaders said they were doing everything they could think of to curb the deaths and appealed for more mental health professionals to join and help out.

At least 128 soldiers committed suicide in 2008, the Army said Thursday. And the final count is likely to be even higher because 15 more suspicious deaths are still being investigated.

“Why do the numbers keep going up? We cannot tell you,” said Army Secretary Pete Geren. “We can tell you that across the Army we’re committed to doing everything we can to address the problem.”

It’s all about pressure and the military approach, said Kim Ruocco, 45, whose Marine husband was an officer and Cobra helicopter pilot who hanged himself in a California hotel room in 2005. That was one month before he was to return to Iraq a second time.

She said her husband, John, had completed 75 missions in Iraq and was struggling with anxiety and depression but felt he’d be letting others down if he sought help and couldn’t return.

“He could be any Marine because he was highly decorated, stable, the guy everyone went to for help,” Ruocco said in a telephone interview. “But the thing is … the culture of the military is to be strong no matter what and not show any weakness.”

Ruocco, of Newbury, Mass., was recently hired to be suicide support coordinator for the nonprofit Tragedy Assistance Program for Survivors. She said she feels that the military has finally started to reach out to suicide survivors and seek solutions.

“Things move slowly, but I think they’re really trying,” Ruocco said.

At the Pentagon on Thursday, Col. Elspeth Ritchie, a psychiatric consultant to the Army surgeon general, made a plea for more professionals to sign on to work for the military.

“We are hiring and we need your help,” she said.

Military leaders promised fresh prevention efforts will start next week.

The new suicide figure compares with 115 in 2007 and 102 in 2006 and is the highest since current record-keeping began in 1980. Officials expect the deaths to amount to a rate of 20.2 per 100,000 soldiers, which is higher than the civilian rate – when adjusted to reflect the Army’s younger and male-heavy demographics – for the first time in the same period of record-keeping.

Officials have said that troops are under unprecedented stress because of repeated and long tours of duty due to the simultaneous wars in Iraq and Afghanistan.

Yearly increases in suicides have been recorded since 2004, when there were 64 – only about half the number now. Officials said they found that the most common factors were soldiers suffering problems with their personal relationships, legal or financial issues and problems on the job.

But the magnitude of what the troops are facing in combat shouldn’t be forgotten, said Rep. Joe Sestak, D-Pa., a former Navy vice admiral, who noted he spoke with a mother this week whose son was preparing for his fifth combat tour.

“This is a tough battle that the individuals are in over there,” Sestak said. “It’s unremitting every day.”

Said Dr. Paul Ragan, an associate professor of psychiatry at Vanderbilt University and a former Navy psychiatrist: “Occasional or sporadic visits by military mental health workers are like a Band-Aid for a gushing wound.”

The statistics released Thursday cover soldiers who killed themselves while they were on active duty – including National Guard and Reserve troops who had been activated.

The Centers for Disease Control and Prevention said the suicide rate for U.S. society overall was about 11 per 100,000 in 2004, the latest year for which the agency has figures. But the Army says the civilian rate is more like 19.5 per 100,000 when adjusted.

An earlier report showed the Marine Corps recorded 41 possible or confirmed suicides in 2008 – about 19 per 100,000 troops.

The military’s numbers don’t include deaths after people have left the services. The Department of Veterans Affairs tracks those numbers and says there were 144 suicides among the nearly 500,000 service members who left the military from 2002-2005 after fighting in at least one of the two ongoing wars.

On the Net:

Army suicide prevention http://www.armyg1.army.mil/HR/suicide/default.asp

Copyright 2009 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Filed under: Suicide, trauma, Violence, , , ,

Mental illness alone is no trigger for violence

Mental illness alone is no trigger for violence
– February 02, 2009

CHICAGO – A new large study challenges the idea that mental illness alone is a leading cause of violence. Researchers instead blame a combination of factors, specifically substance abuse and a history of violent acts, that drives up the danger when combined with mental illness in what they call an “intricate link.”

People with serious mental illness, without other big risk factors, are no more violent than most people, according to the study of more than 34,000 U.S. adults. The research was released Monday in Archives of General Psychiatry.

“Mental illness can provide the knee-jerk explanation for the Virginia Tech shootings,” but it’s not a strong predictor of violence by itself, said lead author Eric Elbogen of the University of North Carolina at Chapel Hill School of Medicine.

Elbogen compiled a “top 10” list of things that predict violent behavior, based on the analysis.

Younger age topped the list. History of violence came next, followed by male gender, history of juvenile detention, divorce or separation in the past year, history of physical abuse, parental criminal history and unemployment in the past year. Rounding out the list were severe mental illness with substance abuse and being a crime victim in the past year.

After the 2007 Virginia Tech killings by a student ordered to get psychiatric treatment, some states considered laws adding mental health questions to background checks for gun buyers or denying weapons to people who’ve been involuntarily committed for mental health treatment.

The new research, which bolsters other similar findings, raises questions about such laws, experts said. Such legislation may be both ineffective and discourage people who need help from getting treatment.

“We are being misled by our own fears,” said Columbia University psychiatry professor Dr. Paul Appelbaum, who wasn’t involved in the new study. “We ought to be concerned about providing good treatment and helping people lead fulfilling lives, not obsessed with protecting ourselves from phantom threats that appear to be unrelated to mental illness.”

U.S. systems to treat mental illness and substance abuse are separate, uncoordinated and could do a better job treating people with both problems, Appelbaum said.

For the new study, the researchers analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions. The original survey in 2001-2002 involved more than 43,000 face-to-face interviews with a representative sample of American adults. Three years later, many of the same people, more than 34,000, were interviewed again.

Questions about violence in both interviews included:

-“Ever use a weapon like a stick, knife or gun in a fight?”

-“Ever hit someone so hard that you injured them or they had to see a doctor?”

-“Ever start a fire on purpose to destroy someone’s property or just to see it burn?”

-“Ever force someone to have sex with you against their will?”

From the responses, the researchers determined what elements raised the risk of violent behavior.

There were 3,089 people deemed to have severe mental illness – schizophrenia, bipolar disorder and major depression – but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10.

The relationship between mental illness and violence is there, “but it’s not as strong as people think,” Elbogen said.

Predicting who will act violently is complex, said John Monahan, a psychologist at University of Virginia’s law school, who has done similar research but was not involved in the new study.

“It is true that our crystal balls are very murky,” Monahan said. “The vast majority of violence that occurs in American society has absolutely nothing to do with mental illness.”

The large national survey, conducted by the National Institute on Alcohol Abuse and Alcoholism, included people living in shelters, hotels and group homes, as well as houses and apartments, but it didn’t include people living in hospitals, jails or prisons.

Rosanna Esposito of the nonprofit Treatment Advocacy Center in Arlington, Va., applauded the study but pointed out the researchers weren’t able to analyze whether the subjects were in psychiatric treatment or not. Medication for serious mental illness can reduce the risk of violence, she said.

On the Net:

Archives of General Psychiatry: http://www.archgenpsychiatry.com

Copyright 2009 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Filed under: psychosis, Violence

Razors Edge – Working with People who Self-Harm – 5 Places in Nottingham

This course hosted by Nottingham HLG is being held on Mon 23 & Tues 24 March 2009. Currently there are 5 places left. If you are interested go to:

http://www.hlg.org.uk/TrngRazEdge.htm

or book at

Email: admin@hlg.org.uk Online:http://www.hlg.org.uk/trainingsubmit.htm Phone: 0115 8599525

Filed under: Impact Training, Suicide, , , , , ,

Open Difficult, Disturbing and Dangerous Behaviour Course in Brighton

If you are interested in attending a one-day DDDB course in Brighton ob 28th April 2009 please contact

http://www.rocc.org.uk/training/course?id=215

Filed under: Impact Training, Violence, , , , ,