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.
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).