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Friday, April 18, 2014

Haiku on Wisdom/ Trade/ Morning/ Measure

Wisdom

Free information
Not necessarily truth
And rarely wisdom

A small child playing
Seemingly oblivious
Getting of wisdom

My daily ‪haiku
Exercise in ‪mindfulness
Searching for wisdom

Be good sweet young maid
And let who will be clever
A mother's wisdom

Trade

Boy followed father
Turning chair legs on the lathe
The carpenter's trade

Begone thou foul trade
Car parts manufacturing
Not Australian

The highwayman's trade
Your money or your life... Choose!
There is no contest

Morning

Morning has broken
Cracked open by midday sun
Burning through to night

Morning glory swells
So nice to still have hormones
At my time of life

Each Tuesday morning
Garbage collectors arrive
Whine, crash, bang, wallop

Mantra in my mind
Bubbles up to the surface
So, why this morning?

Measure

The tailor's measure
Like the doctor's stethoscope
Draped around the neck

Final eulogy
Will not have the time or space
To measure her worth

Like plain Russian dolls
Cooking measures snuggle up
Waiting to be used

On Transverse Myelitis: Accepting your New Self and Direction

Most of us would think that life travels in a sort of straight line, with occasional deviations. Many of us would believe we have rights as human beings. Most of us would think that we are in charge of our lives, and that if things don’t go our way, then it is unfair. None of that is really true. Life is a series of forks in the road, and the direction we take is often related more to chance than to our design. We are not in charge, however much we want to be. We can take some control, each in our own little corner of the world, but as individuals we don’t have much in the way of decisions about war, crop failures and famines, epidemic diseases, cyclones, tidal waves or earth quakes. We do the best we can under the circumstances.
When I reflect on my life and career, I am so aware of some of the forks in my own road so far. At 14 I was somewhat forced by my parents to go to ballroom dancing classes because it would ‘be good for my social future’. I thought it was a stupid idea. On the first occasion, this perfectly proportioned beautiful blond walked through the door with her sister. I was smitten, could not get her out of my mind, and started going to a junior drama club to enable me to be close to her. Well, as of last week we have been married 49 great years.
At the young age of 12, I had an ingrowing toenail removed by my local doctor, and demanded to watch, despite his protestations. I was intrigued how he knew just where to place the local anaesthetic: “You learn that at medical school”. With no doctors in the family, no prior personal experience of medicine, I decided I wanted to be a doctor. Despite having been through a clear episode of depression at 13, and becoming somewhat lazy at school, at the tender age of 16 I found myself in front of 5 eminent doctors being interviewed from a place at King’s College Hospital medical school. I must have been incredibly naive in my answers about school life, my life in general, my average sporting ability. My answer to one question they asked me may have made the difference: “What books have you been reading lately?” One of the books I raved about (at 16!) was Freud’s ‘Psychopathology of Everyday Life’ a brilliant every-day-language exploration of slips of the tongue, mis-remembering, and dreams. It had been lent to me by an older friend at school, by chance. I gained a place at Med School; later I became a psychiatrist.
In 1973, Jan and I went to a conference on psychotherapy in Norway, as you do. Well, it looked interesting, we had never been to Norway, and we needed a tax-deductible break from being in a busy general practice. We had such hilarious times with a group of Australians, and they raved so much about psychiatric training and opportunity in Australia, that we emigrated in late 1974.
There is so much chance in all of this. You never quite know where it will all lead, and what other disasters may follow as a result of that fork in the road (but that is all another story). The point I am making is that you take decisions for what appear to be sound reasons at the time, even if the ideas were planted by accident. All of that is a long preamble to Transverse Myelitis.
It happens swiftly, often for no apparent reason, and usually with no known cause (as far as we know at this juncture). You are paralysed, each slightly differently depending on the spinal level and the extent, and whether a doctor recognises this rare syndrome quickly enough to put you on steroids – which appear to have some impact in reducing the long-term problems. There is little you can do in those early days. You accept that the doctors, nurses, physios all know best. Some of us get depressed, and just want to disappear down a worm-hole until it is better. Others of us get angry, want to get even, and rail against the whole damned thing. Sometimes, this is useful in driving us to overcome disability and do our damnedest to get back to the old person, and the previous life.
The truth is that this Transverse Myelitis is a fork in the road. We don’t have any right to a total cure. We don’t necessarily have much in the way of control over how we progress. Somehow we have to come to terms with ‘the new me’. Somehow we have to accept this, and work out what we can do with ‘the new me’.
I am lucky. Four years down the track, and I am still walking (sort of, and not very far). I occasionally lose balance if I turn too quickly or get distracted. I am wobbly on my feet, and walking down a corridor I must look like a ship at sea sometimes. I have lost considerable bulk and power in my calves, thighs and buttocks despite striving to continue to walk, climbing stairs several times a day, and getting on an indoor bike once or twice a week for 30 minutes. I have residual urgency and hesitancy with waterworks, which makes travel difficult. I have a slow bowel, which gets irritable from time to time and ruins my carefully set routines. I pass wind occasionally in public, which has made me slightly agoraphobic; I don’t very much like being in public places.  I have chronic right-sided chest pain, which I can mostly ignore, meditate away, or for which I take a couple of paracetamol tablets. I used to be a 2nd Dan Karate teacher; now I am not.
I can still supervise staff and students, and they accept that I may have to rush off to sort myself out. I continue to consult as a child and family psychiatrist, and seem to be effective; I am certainly busy in the couple of days a week I can manage before I get exhausted. But I am not me as I planned to complete my professional career. I have taken a new pathway, and being angry or distressed about all of this does not help. I just have to get on with it.
I chose last year to stop doing all sorts of things I could no longer really manage. I used to rush around the country, sitting on committees and pretending to be important; I don’t do that any more. I used to attend numerous conferences every year; I don’t do that any more. I was always flying somewhere; I don’t do that any more. I used to be on boards and committees, chairing this and that and the other; I don’t do that any more. I used to give up to 50 presentations a year, often to community groups, and often after hours; I don’t do that any more. I used to try to influence media by talking on television and radio, and writing for newspapers and magazines; I don’t do that any more.
The bonus has been that last year in conjunction with various research groups, I completed and published about 20 professional journal articles, and 6 books. I just manage a few undergraduate and graduate students, a few residual pieces of research, and a few colleagues I mentor. I have had time to play on Facebook, Twitter, and this blog. And, I have had more time with my beloved Jan.

Am I the same person? Of course not, but ‘Yes’. Am I happy? I still get distressed about my symptoms, and work hard at trying to reduce their impact. But, ‘Yes’, I am happy and constructive and satisfied. I am not the lucky medical student, or the much-loved family doctor, or the striving psychiatrist, or the ‘national’ expert in youth suicide prevention, or the media tart. I am choosing to do what I see could be important for my family life, my life, my body, my mind, and my integrity. I have embraced this new pathway; unexpected as it was. I am a slightly different me. And that is ‘OK’.

Monday, April 14, 2014

Monday Free Download: Adolescent Depressive Symptomatology: Improve Schools or Help Students?

Despite the increasing interest in programs designed to improve the social ecology of schools, surprisingly little is known about whether differences between schools influence student mental health. This 3-year prospective, naturalistic study examined the school effect on adolescent depressive symptomatology (measured by the Center for Epidemiological Studies Depression Scale, CESD) among 2,489 students from 25
Australian high schools. Multilevel modelling techniques (HLM) formed the basis of the statistical analyses.There were statistically significant school effects on students' depressive symptomatology; however, these were much smaller than expected. Nearly all of the variation in CESD depression scores was found to be at the student level, indicating that the potential mental health gains from reducing risk factors in school social environments may be extremely limited and have little effect on student depressive symptomatology.

Go to http://www.familyconcernpublishing.com.au
Then: 'Resource' Tag
Download here: *Adolescent depressive symptomatology Improve schools or help students?

Roeger, L., Allison, S., Martin, G., Dadds, V., & Keeves, J., 2001. Adolescent Depressive Symptomatology: Improve Schools or Help Students? Australian Journal of Psychology, 53: 134-139.

Sunday, April 13, 2014

Suicide in young people should never occur - Ever! So what should we do? (3: Let's help therapists to get it right!!)

I have just completed an online questionnaire about priorities for mental health funding for research in young people, in advance of a national, high-level, structured Delphi group process seeking consensus on 44 proposed programs. This will consist of a group of national experts - presumably on youth mental health. I guess we can assume they will be more or less biased toward their own ideas. Given my disabilities and my inability to travel, I will not be there to represent my own biases. (To tell you, the truth I suspect I am unlikely to be invited.)
Several of the proposals sounded incomprehensible or incredibly complex and probably not feasible anyway, to this poor ageing mind. However, several proposed projects sounded fascinating, but with a bias toward biomedical questions that might (or might not) provide answers about the adolescent brain, and how it preferentially responds to various drugs, for instance in the context of psychosis. There were a couple of what I would consider to be ‘dodgy’ projects about novel drugs like Ketamine, originally used as an anaesthetic for horses and more recently in humans, and recently proposed as an antidepressant - but with very little in the way of serious scientific research to date. Whatever, most of the proposed projects will take years to set up and complete, soak up multimillions of dollars, and not necessarily have much impact on the mental health of adolescents, nor reduce suicide rates, for many years to come.
There were only a couple of proposed programs on preventing youth suicide, one a national program of mental health assessment on 1st year high school (but with nothing suggested about what everyone has to do then), and another about training professionals to better recognise the symptoms and signs of possible suicidality (again, nothing about what you would do then). And we do have a plethora of so-called early intervention services, but recently there are big questions being raised about some that they may not be getting the most serious of referrals, or have the skills to do the work required, or the staffing to meet the demand (m.theage.com.au/national/bitter-rift-on-youth-mental-health-provider-headspace-20140412-36k60.html).
Listen, I believe we CAN find troubled young people before they do something that everyone regrets. I have written repeatedly about how we can intervene with those young people in schools and in the community. But at the end of the line, we need well-trained, highly competent and energetic, well-supported therapists to do the work with the most complex and difficult of cases.
From a strictly personal point of view (of course), we have a desperate need to find out what therapies work best for young people, and then provide thorough training programs with ongoing supervision. What I hear, from so many sources, is that therapists are often poorly trained in different therapies, lacking regular supervision, and groping in the dark to work out what to do with severely troubled young people. For instance, I recently heard of a therapist using DBT therapy for a group, from which young people dropped out – because she was ‘just reading from the manual’. I fear this may be all too common.
I suspect it may be worse than that. There are therapies that are very well researched, with universal support from a majority of therapists, but there is a lack of rigorous research work to show they work in the longer term with particularly complex problems. As an example, Cognitive Behavioural Therapy (CBT) would be acknowledged by the majority of psychologists as a core therapy for a wide range of mental health conditions in young people. However, it may not work with suicidal kids. Several years ago we completed a piece of research on group therapy for self-harming young people using CBT. By self-harm, I mean either self-injuring or suicidal, or both. With some money from a US group (because we could not get funding support in Australia), we embarked on a multisite randomised controlled study of a group CBT. 140 young people began the study, and sadly there were many dropouts, but despite this, the overall results were very poor (Hazell et al., 2009). Yet, if you ask therapists about their usual first line treatment, they will immediately say CBT.
More recently we completed the very first RCT on mindfulness and its use in young people on a shoestring budget, and found good results in ‘run of the mill’ young people from child guidance clinics (Tan and Martin, 2014). But there is a need for replication and further studies. And ‘run of the mill’ does not necessarily mean seriously suicidal.
Another shoestring study of ours, that DID include suicidal young people, has shown excellent results at follow-up (Martin, Martin, et al., 2013), but the numbers were small, and there is a need for replication and large-scale studies. And there is a problem with this study in that it is one of a very wide range of ‘Expressive’ therapies, generally dismissed by logical, left-brained scientists, and psychology and psychiatry as having no serious research attached to them.
AND YET, if you go into any clinic for young people with mental health problems, you will find all sorts of ‘expressive’ therapeutic interventions for which there is minimal research support – commonly variants on variants. They are passionately espoused, and often done behind the closed doors of the consulting room. This, of course, is one of our main problems in child and adolescent work; nobody really knows what is being done behind closed doors, even in the best of clinics with good availability of supervisors.
Don’t get me wrong. I am not discounting expressive therapies. In fact, increasingly, I am hearing about music therapies, dance therapies, and others that DO work with seriously ill young people. But so far, the studies have been very few and far between, so they get easily dismissed. But then ARE the studies on expressive therapies rare? Or do we just not hear about them?
Well, who really knows what is being done behind closed doors?
And nobody in these clinics is keen to look at outcomes. There is a national program ostensibly looking at outcomes in child and adolescent mental health, but the resistance at grass roots level is profound, with fewer than 50% completing the measures. But then in 5 years, no-one has ever heard back from the national process as to how their personal measures are going, and whether their patients have made a measured satisfactory process.
So coming back to the Delphi process. I completed my questionnaire, and at the end they asked for ‘suggested other projects’. I suggested a national survey of just what expressive and other therapies are being used across the country in child and youth services, and what the evidence for them is? In addition we need to know about ongoing supervision practices, and updating of skills. The paramount issues are: “What works with seriously troubled young people?” and “What is acceptable to young people, so that they do not drop out?” and “How can we bring the best possible skill to the issue of managing suicide at the clinic level?” and “How can we train therapists to a sufficient standard?”
If we are serious about wanting to reduce suicide in young people, we cannot any longer rely on half-baked people doing half-baked therapies. We have to actively, explicitly and aggressively MEASURE OUTCOMES. How can we possibly go on believing we know what we are doing, if we don’t measure outcomes, don’t disseminate the results of that, and don’t discard therapies that DO NOT work – whatever their theoretical basis?
I DON’T SUPPOSE MY SUGGESTED NATIONAL REVIEW AND PLANNING FOR BEST PRACTICE THERAPIES WILL OCCUR.

References
1.          Hazell, P., Martin, G., McGill, K., Kay, T., Wood, A., Trainor, G. & Harrington, R., 2009. Group therapy for repeated deliberate self-harm in adolescents: Failure of replication of a randomized trial. Journal of American Academy of Child and Adolescent Psychiatry, Jun; 48(6):662-70.
2.          Martin, S., Martin, G., Lequertier, B., Swannell, S., Follent, A. & Choe, F., 2013. Voice Movement Therapy: Evaluation of a Group-based Expressive Therapy for Non-suicidal Self-injury in Young Adults. Music and Medicine. 5:1, 31-38. doi: 10.1177/1943862112467649
3.          Tan, L. & Martin, G. (2014). Taming the Adolescent Mind: A randomised controlled trial examining clinical efficacy of an adolescent mindfulness-based group program. Child and Adolescent Mental Health, 19. Impact Factor 0.635. Accepted (Dec.2013).
4.

Saturday, April 12, 2014

Haiku on Rescue/ Offer/ Escape/ Shift

Rescue

Red and yellow caps
Little surf life savers train
For the big rescue

New helicopter
For the search and rescue team
Rotary angel

She stopped taking drugs
Threw the alcohol away
Mental health rescue

Offer

Spring offered A deal
I'll come early; you can sleep
Winter answered snow

It's a free offer
With absolutely no strings
Send me your email

A new job offer
Working just for commission
No real salary

Escape

T'was love at first bite
Single drop of blood escaped
Dribbled down his chin

Escape daily grind
Move up to the Sunshine Coast
Lose television

We cannot escape
Our lives are planned before birth
Never see the script

Shift

Makeshift raft of sorts
Kon Tiki expedition
What a lot of luck

Slip beneath her dress
Slight shift in the evening plan
Slide back into bed

Today I feel good
Yesterday was a trial
Shifting sands of life

Haiku on Cheat/ Novice/ Staple/ Faint

Cheat

Old English card game
Cheat with "three queens"; which are not
Dare someone call you?

Training child tastebuds
Pumpkin in chocolate cake
Mothers cheat sometimes

Cheated of summer
Bush fires rage across country
Hopes lie in ashes

Novice

Novice lay face down
Body in cruciate form
Her hair newly shorn

Stood on wobbly legs
Smiling, but really perplexed
A novice biped

Power swelled inside
Released, it smashed mother's vase
Novice Mage flowered

So, this goes in there
And then what do I do next?
A novice lover

Staple

Salt, fat and sugar
Staples of western diet
Lifestyle diseases

Refugee silence
Their lips stapled together
Human rights protest

Bent piece of metal
Foundation pillar of life
The humble staple

Faint

I am still awake
Bemused to see today's word
I feel rather faint

Morning assembly
Small girls breathe recycled air
Hellfire hymns make faint

Would you care to dance?
A faint smile as their eyes met
Step into future

Washed her hands again
The faint smell of blood remained
Lady Macbeth's curse

Saturday, April 5, 2014

Suicide in young people should never occur - Ever! So what should we do? (2: Let's Change Schools)

I had a lengthy conversation the other evening with a school counsellor from a country school. They had received three copies of our small book ‘Seeking Solutions: a Guide for School Staff’, which has now been sent free of charge to every high school in Australia for which we could get an address. Just for the record, we also sent one copy of the companion books ‘Seeking Solutions: a Guide for Parents’, and ‘Seeking Solutions: a Guide for Young People’. The development of this series is solidly grounded in a qualitative research program we did several years ago, interviewing and videotaping over 60 young self-injurers and over 40 professionals about their opinions about what needed to be done. It also follows a dozen, more traditional, cross-sectional studies and a 3-year longitudinal study, as well as our 2009/10 national epidemiological study.
OK, back to our counsellor. They had read the booklets, but had more questions. Great. “How do you manage the parents of someone currently self-injuring?” “How do you manage the friends of a person who is self-injuring?” “How do you get back-up resources for the school, and links to mental health services?” We worked our way through those, and got to ‘school ethos’. The person was new to the school as a counsellor, and struggled to tell me about the values on which school teaching programs were based.
We began to discuss the sort of programs that could be embedded in the school curriculum that might help young people to develop resilience and optimism to protect them from bullying and some of the problems deriving from abuse in the home. They had not heard of ‘MindMatters’ (http://www.mindmatters.edu.au), and were pretty sure it was not part of their school. Nor had they heard of ‘KidsMatter’ (www.kidsmatter.edu.au), and did not believe it was part of their junior school. They originated from another country, so we did some basic discussion around the idea that improved resilience might improve learning outcomes. That seemed to be a bit of a novel idea, and I cast around for something they might of heard of like Social and Emotional Learning (http://www.casel.org/social-and-emotional-learning/) for which there seems to be a solid research base. SEL seems to be gaining ground in Government Education Departments like Queensland (http://education.qld.gov.au/actsmartbesafe/teachers/sel.html) and Victoria http://www.education.vic.gov.au/school/principals/health/pages/socialemotion.aspx), and of course provides some of the basic thinking behind ‘KidsMatter’.
So, by this stage I was feeling a bit despairing, and fired off the names of several programs for which there is a strong evidence base, and that might have been heard of, like ‘Friends’ (http://pathwayshrc.com.au/friends-life-8-11-years/) or the Resourceful Adolescent Program (http://www.rap.qut.edu.au). Blank...
Now, look, I realise this may have been a new person, recently trained, (they didn’t sound like it), or perhaps they were in an environment that did not discuss these things (difficult to imagine). I have done many, many hours of presenting to individual schools’ staff, groups of school counsellors, school based youth health nurses, over many, many years. I have been to AGCA conferences (http://www.agca.com.au). I was part of a national committee for MindMatters, and later on the Evaluation Subcommittee for many years. At the end of the extended phone call, I was left speechless (pun intended). I was left deeply concerned for the welfare of the children at the school, and seriously worried about my post yesterday on this blog Suicide in young people should never occur - Ever! So what should we do? (1 Facts and Figures and a challenge)” and the challenge to schools that I raised.
Am I spitting into the wind? Can schools ever manage to take on the training of resilience, optimism, and wellness necessary to provide a serious level of Mental Health Promotion capable of undermining depression and suicidality?
One issue is clearly about having staff members who understand the issues about the power of Mental Wellness to undermine development of ill health. A special issue is about counselling staff being in sufficient numbers to help schools understand these issues, and train them into all staff members.
And what about principals? I remember in our discussions during the emergence of MindMatters, that the program was ‘optional’. That is the school did not have to take it on. The decision seemed to be at the level of the Principal. Is this still the case? I do not know. I am not an educationalist; there is probably an immense amount about which I am ignorant. But let me put up a proposition... One side issue first...
I have become sick to death of all of the public newspaper and radio discussion about NAPLAN (http://www.nap.edu.au/naplan/naplan.html). I work with kids and adolescents in therapy. I have listened with concern to them all talking about how their whole school program seems to be taken up by training for NAPLAN, how stressed the teachers are about NAPLAN, how boring the whole NAPLAN exam is. I have discussed the issue with some teachers who resent the power of intrusion that NAPLAN has to disrupt the process of learning anything other than numeracy and literacy. Personally, I think this is bureaucracy gone mad trying to set up competition between schools in some vain effort to improve standards.
And it is all so back to front. It does nothing for suicide prevention. I suspect it ultimately does little for how future generations will lead their lives.
PROPOSITION
Can we develop a massive national bureaucracy to monitor how many schools have taken up any social and emotional wellbeing programs? Can we use that bureaucracy to measure and report on just what is being taken up, and just how well it is being taught? Could we ensure that every teacher and every counsellor in Australia is well versed in whatever the program, or programs are? Could we measure the emotional health and mental wellness and social skills of every young person in a school, and compare them year by year, and compare schools on the basis of how successful they were in developing Mental Health, and lowering anxiety, depression, bullying, and school dropout.
I believe we could turn Australia’s current pathway to disaster around, and begin to reduce negative outcomes from family abuse of all sorts. I believe we could give the young people in our charge, the best possible skills for the rest of their lives to avoid even the merest thought of suicide.
If the SEL research is correct, Australia would be able to compete successfully with any country in the world in terms of quality of education, and skills in all the so-called core subjects.
We could call the program something clever like WELLPLAN, or OPTIPLAN, or Schooling for Health, or MindfulEducationforLife.
For anyone remotely interested, the Seeking Solutions books are available from Family Concern Publishing (http://www.familyconcernpublishing.com.au), for the enormous cost of about $2.00 each (plus p&p, of course).

But then, if we had MindfulEducationforLife, no-one would be remotely interested such books, because Non-suicidal Self-injury (NSSI) might have been eradicated as well. Bad luck Graham...