A case study extract from ‘Forensic Music Therapy’ – Working with Conflict

Stella Compton Dickinson, editor

This is an edited extract from Forensic Music Therapy: A Treatment for Men and Women in Secure Hospital Settings edited by Stella Compton Dickinson, Helen Odell-Miller and John Adlam. This case study comes from Chapter 7, ‘Working with Conflict: A Summary of Developments in the Long-term Treatment of a Man Suffering with Paranoid Schizophrenia Who Committed Manslaughter’, by Stella Compton Dickinson and Manjit Gahir.

Introduction

This chapter describes the process of long-term music therapy over seven years with a man who we shall call “Ewan.” Ewan has given informed consent for case material to be used in telling the story of his rehabilitation; his real name has not been used. Ewan suffered with paranoid schizophrenia and whilst actively psychotic with hallucinations and delusions, he killed a man.

Overview

Committed to hospital for an indefinite period after being convicted of the offence, Ewan spent ten years in high secure detention without undertaking therapy until he requested a referral to music therapy, “to learn to play the violin” as his grandfather had done. He engaged in music therapy as his main psychological treatment. The intervention and its impact were new to the clinical team who had to adjust to the fact that internal changes were starting to happen for a patient who they had known to be static for many years. Thus their own past experiences, their judgments of Ewan in the face of fear when he had erupted with violent outbursts, and their perceptions for his future were all challenged.

Music therapy

Ewan’s fundamentally chaotic presentation was marked by fixed perseveration, which is typical of schizophrenia. Notable in his early musical improvisations were repeated, stuck, desperate, and stabbing sounding attacks on the piano keys. This represented exactly his situation and offence: angry, locked in, stuck, as if he had nowhere to turn. The therapeutic work required orientation to the here and now, rather than unlocking too much past material at once. Nevertheless, Ewan recognized how he could receive rather than reject my non verbal musical support. This elicited a maternal transference. Towards the end of the second assessment session, Ewan rushed from the room, having exclaimed his recognition within our musical improvisation that “you are supporting me! I have not felt like that since I was with my mother.”

The significance of this was central to the therapy as Ewan had been unable to mourn the death of his biological mother. He returned explaining that this experience had “brought a tear to my eye.”

Starting the treatment process

Ewan had never experienced any previous psychological therapy at all, so the same weekly place and time was an entirely new experience for him, which he almost religiously observed. As the therapy progressed, he became more proactive in ensuring that regular physical health appointments were not timetabled to coincide, as nothing had to come between him and his music-making. Over time, as he became more trusting in the continuity of his life and less fearful of sudden abandonment, he gradually extended his range and felt safe to play the piano on his own rather than with me. Ewan began to take responsibility for his own actions rather than remaining over-identified with his own victim self-state.

The mother–child dyad and symbolic musical representations

In session 12, Ewan elucidated on his feelings of stupidity and how he played on these as a childhood strategy. He said he had taken to “acting stupid” whenever he felt threatened by his father. The mother–son relationship was enacted symbolically as a maternal transference developed. The merged relationship that developed between Ewan and his biological mother during childhood was cemented when both mother and son cowered from the violence and physical abuse of the father. This relationship was represented musically in session 2 in which initially Ewan played mournfully on the recorder, copying my choice of instrument, then merging with it and introducing a sensual, rocking rhythmic pulsation which indicated an as yet unconscious underlying erotic transference. The music then became violent and angry as Ewan repeatedly hit a small glockenspiel as if he was a frustrated child waiting for dinner. This had a direct correlation to verbal material in which Ewan described the intimacy and frustrations that he felt with his mother. After this the music became mournful and sad although it finished in a resolved, harmonious fashion.

The index offence: developing victim empathy

In reference to the man who he had killed, Ewan attempted to make an offering in musical terms by sitting at the piano to play a piece which he entitled “Requiem.” At the time this felt sincere but also very sad, as I perceived that Ewan felt very clumsy and inadequate in trying to address such a huge and tragic event. From this state, the first expressions of remorse at the magnitude of his violent act began to emerge. Perhaps the fluctuations between reflecting on his offence and reflecting on his childhood suggested how Ewan was trying to make links in understanding why he had committed his offence.

Conclusion

The individual music therapy was characterized largely by a positive transference. Ewan completed his mourning process in the following two years of group therapy where he discovered how to be part of a “family,” as well as how to feel included and valued by others. He remains in custodial care at a lower level of security. At his care program review as the therapy closed, he described his recovery process in music therapy as “akin to the raising of Lazarus.” This biblical reference to Christ’s greatest miracle probably says at least as much about Ewan’s internal morbid state of loss, including loss of hope prior to engagement in music therapy, as it does about his creativity and ability to express himself and to develop through music therapy in a way which, after ten years of stagnation, he may have felt was miraculous.

Copyright © Jessica Kingsley Publishers 2012

 

A celebratory evening at the 2012 BMA Medical Book & Patient Information Awards

Winner Charlotte Clarke with commissioning editor Rachel Menzies

The impressive BMA House in Tavistock Square, London, served as an excellent backdrop to an illuminating ceremony last night for the 2012 BMA Medical Book and Patient Information Awards.

We are thrilled to announce that first prize in the Health and Social Care category was awarded to the JKP title, Risk Assessment and Management for Living Well with Dementia, edited by Charlotte L. Clarke, Heather Wilkinson, John Keady and Catherine E. Gibb. The book is part of our well-established series, the Bradford Dementia Group Good Practice Guides.

Charlotte Clarke was at the ceremony to accept the award and was delighted to have been recognised by the British Medical Association for the editors’ collective achievements with the book.

Here is what one of the BMA reviewing panel said about the title:

“This is a novel and truly excellent book, made all the more acceptable by its brevity and clarity. It has certainly impressed me as an essential aid to those who care for people with dementia and it sets-out how risk should be assessed and managed in a clear and reassuring manner. It is an excellent slim book with a really helpful approach in an increasingly important field.”

Professor Averil Mansfield CBE, Chairman of the BMA Board of Science commented that it was “no mean feat to be shortlisted”, as they received several hundred individual entries for the book awards. Hearty congratulations must therefore go to the authors of the four Highly Commended titles from JKP and Singing Dragon, which are as follows:

After the Suicide by Kari Dyregrov, Einar Plyhn and Gudrun Dieserud – Health and Social Care category

Understanding Behaviour in Dementia that Challenges by Ian Andrew James – Health and Social Care category

Comforting Touch in Dementia and End of Life Care by Barbara Goldschmidt and Niamh van Meines – Popular Medicine category

Making Sense of Near-Death Experiences by Mahendra Perera, Karuppiah Jaghadheesan and Anthony Peake – Psychiatry category

The evening was attended by medical professionals, authors and publishers, of which editors Rachel Menzies and Emily McClave as well as marketing & publicity executive Ruth Tewkesbury were present on behalf of JKP. Books were judged on accuracy, appropriateness, quality of design and production, originality of content, approach and value for money.

 

Charlotte Clarke receiving her award from the BMA President, Professor Baroness Hollins, FRCPsych, FRCPCH, FRCP

Highly commended JKP author Ian Andrew James with winner Charlotte Clarke

 

Singing Dragon author Barbara Goldschmidt (second left) with JKP staff Emily McClave, Rachel Menzies and Ruth Tewkesbury

The full list of highly commended titles and award winners can be found here.

A great evening was had by all, and once again, congratulations everyone!

Ruth Tewkesbury
Marketing and Publicity Executive

“Asleep for ages”: Perspectives on sleep in history

Andrew Green, co-editor of Sleep: Multi-Professional Perspectives writes on how ideas about sleep have changed over time, and how sleep has been historically regarded in different ways.


Despite centuries of speculation and research, we still do not know what sleep really is, or exactly what it is for. Allan Rechtschaffen suggested that ‘If sleep does not serve an absolute vital function, then it is the biggest mistake the evolutionary process ever made’ (1971, p.88) and it does seem reasonable to conclude that unless it gave a species an advantage, sleep would have become extinct by now. Noting that all animals sleep, Paterson (2012) shows how the sleep of some animal species has adapted in surprising ways in order to meet to particular needs. She also discusses some of the functions that we now think sleep serves, although these modern ideas contrast with theories that have developed through the ages.

According to Scrivner (2012), in ancient Greek mythology sleep

“…was made the jurisdiction of anthropomorphic deities and weird demons whose actions determined both our shifting states of consciousness as well as the endless shift of day into night and back again. The Greek god of sleep, Hypnos, and Nyx, the goddess of the night, are chased away each morning by … Eos, the dawn” (Scrivner 2012, p.271).

However, in ancient Greek philosophy, in one of the earliest explorations or the causes and purposes of sleep Aristotle (384 BCE–322 BCE) made what now seems like a statement of the obvious:

“It is inevitable that every creature which wakes must also be capable of sleeping, since it is impossible that it should continue actualizing its powers perpetually. So, also, it is impossible for any animal to continue always sleeping.” (Aristotle)

He went on to explain how sleep relates to the cardinal humours (blood, phlegm, black bile and yellow bile) and to changes in body temperature that result from eating and digestion

“… in every animal the hot naturally tends to move […] upwards, but when it has reached the parts above [becoming cool], it turns back again, and moves downwards in a mass. This explains why fits of drowsiness are especially apt to come on after meals; […]. When, therefore, this comes to a stand it weighs a person down and causes him to nod, but when it has actually sunk downwards, and by its return has repulsed the hot, sleep comes on …” (Aristotle).

Zimmer (2005) shows how Thomas Willis, though a pioneer in neuroscience, was still a man of the mid-seventeenth century and held that sprits flowed through the nervous system; emotions were produced by movements of the sensitive soul (as opposed to the humours of the heart) and spirits, which expand in happiness, could not flow without rest – hence the need for sleep. Willis attributed narcolepsy (although it was not formally identified then) and sleepiness to an excess of blood in the brain which cramped the animal spirits, making them unable to flow; he prescribed bleeding and newly available coffee. Sleepwalking resulted from spirits travelling down the spine causing the person to walk. Although such ideas might seem quaint now, Willis, like Aristotle, was at least finding explanations for phenomena in sleep that excluded supernatural intervention.

In the nineteenth century Robert Macnish, a Scottish physician and surgeon, was referring to the phenomenon of night terrors – known then as nightmare (see Green 2012) – not as the visitation of evil spirits, but as an illusion; however, he noted that ‘Many a good ghost story has had its source in the illusions of nightmare’ (Macnish n.d., p.130; first published 1834). Evenso, while a rational scientist, Macnish still did not know what sleep was for:

“Sleep, being a natural process, takes place in general without any very apparent cause. It becomes, as it were, a habit, into which we insensibly fall at stated periods, as we fall into other natural or acquired habits” (Macnish n.d., p.17; first published 1834)

Early in the twentieth century Addington Bruce reviewed some of the theories about the function and causes of sleep. He observed that explanations had ‘usually resolved themselves into descriptions of states that accompany sleep rather than demonstrations of the factors that cause it’ (Bruce n.d., pp.2–3; first published 1915). For example, he noted that ‘deficiency of blood in the brain’ (p.3) did not signify a cause, but proved only that circulatory changes occur in sleep. Bruce also dismissed theories that sleep can be attributed to accumulation of toxins in the blood or that monotony (see Sidis 2010; first published 1909) was the cause. He asserted that sleep:

“…is an active positive, positive function, a protective instinct of gradual evolution … its object being not so much the recuperation of the organism … as to save [it] from the destructive consequences of uninterrupted activity” (pp.8–9).

He did, however, suggest that ‘most us sleep longer than is really necessary’ (p30).

While research on sleep flourished during the twentieth century, and into the twenty-first, – see Kroker (2007) for a detailed account – suggestions that we could sleep less, or barely at all, have persisted and the idea that sleep is a waste of time remains widespread. In the 1950s and 60s writers looked forward to times when we might sleep less – the most bizarre suggestion being the ‘electrosone’, a device that was to allow us to have only two hours’ sleep a night (see Green 2012a).

At the present time debate continues about unprescribed use of modafinil, a stimulant used for treatment of narcolepsy, and whether it can allow us to get by with less sleep (for example, see this Guardian article.) But whatever the short-term benefits may be, it seems unlikely that we can safely reduce our sleep substantially in the longer term.

We know that sleep is essential for memory, learning and performance of many activities (see Green 2012b, for example) and that the links between sleep and good health are many. Put one way, we might say that if the Good Lord did not intend us to sleep He would not have given us the night – or put another: millennia of evolution are unlikely to have got it so wrong.


References:

Aristotle (2011-09-30). On Sleep and Sleeplessness [Illustrated]. Kindle Edition.
Bruce, H.A. (n.d) Sleep and Sleeplessness. Kila, MT: Kessinger Publishing, LLC. (Original work published 1915).
Green, A. (2012a) ‘Sleeping on it.’ In A. Green and A. Westcombe (eds) Sleep: Multiprofessional Perspectives. London: Jessica Kingsley Publishers.
Green, A. (2012b) ‘A Question of Balance: The Relationship Between Daily Occupation and Sleep.’ In A. Green and A. Westcombe (eds) Sleep: Multiprofessional Perspectives. London: Jessica Kingsley Publishers.
Kroker, K. (2007) The Sleep of Others and the Transformations of Sleep Research. Toronto: Toronto University Press.
Macnish, R. (n.d.) The Philosophy of Sleep. Bibliolife. (Original work published 1834).
Paterson, L.M. (2012) ‘The Science of Sleep: What is it, What Makes it Happen and Why Do We Do it?’ In A. Green and A. Westcombe (eds) Sleep: Multiprofessional Perspectives. London: Jessica Kingsley Publishers.
Rechtschaffen, A. (1971) ‘The Control of Sleep.’ In W.A. Hunt (ed) Human Behavior and its Control. Cambridge, MA: Shenkman Publishing Company, Inc.
Scrivner, L. (2012) ‘That Sweet Secession.’ In A. Green and A. Westcombe (eds) Sleep: Multiprofessional Perspectives. London: Jessica Kingsley Publishers.
Sidis, B. (2010) An Experimental Study of Sleep (Kindle edition). Evergreen Review Inc. (Original work published 1909).
Zimmer, C. (2005) The Soul Made Flesh. London: Arrow Books.

Professional and Therapeutic Boundaries in Forensic Mental Health Practice

By Dr. Anne Aiyegbusi and Gillian Kelly, editors of the new volume in the Forensic Focus Series, Professional and Therapeutic Boundaries in Forensic Mental Health Practice.

Photo: Dr. Anne Aiyegbusi (left) and Gillian Kelly.

The word ‘boundaries’ is used a lot in forensic mental health practice. This is not surprising given that by definition the offender populations who constitute the client groups in forensic services have breached boundaries in serious ways. It is also clear that forensic populations include a large percentage of people who have also had their personal and bodily boundaries breached in traumatic ways during their early development. 

When groups of people with these backgrounds are locked up together in secure settings where they feel disempowered, restricted and themselves to be victims of the system, the task professionals have of establishing and maintaining safe boundaries is a challenging one. Although there is little research evidence available, a picture emerges from clinical practice that suggests there are complex gender issues at play with regard to boundary violations in forensic settings. Indeed, if we turn to newspaper reporting in the United Kingdom we will find that there are regular stories of female staff accused of sexual relationships with male patients in secure services. 

A complicating factor that emerges in forensic services is that clients have a combination of vulnerability and risk. Clients may be vulnerable to being abused and at risk of abusing. Sometimes it is not easy to separate vulnerability from risk, especially when clients are high profile or severe offenders. Working with this combination and maintaining balance is a particularly delicate task.

This book provides detailed accounts of therapeutic practice in all forensic settings, explaining exactly how clinicians from a range of different disciplines work with complex boundary phenomena in the context of nursing, psychotherapy, arts therapies, family therapy and psychology. Importantly, the perspectives of victims and perpetrators of professional boundary violations in psychological therapies are included in this book which provides an insight into the impact of professional corruption on clients who enter into therapy to recover but end up being used by their therapists. The perspective of perpetrators is included by reference to a service in the USA specifically for boundary violating professionals.

This book is important because establishing and maintaining professional and therapeutic boundaries in forensic mental health practice is crucial and yet shockingly there is little available literature to support clinicians in the complex task they have. In particular, there is a complete absence of guidance which elucidates the reality of day to day clinical work with its difficult balancing acts, slippery concepts, confrontation with offence paralleling  behaviours and being tested, pushed and pulled out of professional role. 

This book is a valuable resource for clinicians of all disciplines and grades who practice on the front line of forensic practice because it clarifies that they are not alone in facing the boundary challenges inherent in this work. The key roles played by supervision and reflective practice are emphasised throughout the book. Training in boundaries work is also referred to. These are the tools that enable effective clinical work which is important information for managers and academics organising services and providing education for front line workers in order that they ensure their products are sufficiently robust.

VIDEO: Nick Luxmoore reads an excerpt from his new book, ‘Young People, Death and the Unfairness of Everything’

In his new book, school counsellor, teacher, youth worker, Psychodrama psychotherapist, trainer and author Nick Luxmoore explores the problems that arise when death is not openly discussed with young people and offers invaluable advice about how best to allay concerns without having to pretend that there are easy answers. He covers all of the key issues from the physicality of death to the fear of not existing to the way young people’s morality develops and he provides expert insight into the impact these subjects have on young people’s behaviour.

Here, Nick introduces the book and reads an excerpt from the chapter, “Death as an authority figure”.

Copyright © Jessica Kingsley Publishers 2012.

The Therapeutic Milieu Under Fire

By John Adlam, Anne Aiyegbusi, Pam Kleinot, Anna Motz and Christopher Scanlon, editors of the new volume, The Therapeutic Milieu Under Fire.


What therapy can be offered to people with forensic histories and how might it work? What can we learn about the minds of offenders from observing our own reactions to working with them? How do teams working with dangerous and disturbed people survive? How can organisations themselves become perverse and abusive, and how is it possible to prevent this through reflective practice and team development?

In The Therapeutic Milieu Under Fire, we explore these and other essential questions in forensic work in organisations and institutions. We work with highly complex, disturbed, dangerous and endangered people; trying to keep their thinking alive despite conscious and unconscious assaults on the therapeutic relationships and on the milieu itself.

This book is based on a series of seminars organised by practitioners that promoted psycho-social enquiry into the nature of forensic systems of care and the qualities of their relationship to the excluded outsider.

This book also reflects on this particular historical moment and it movingly describes the impact of the lethal attacks that have been carried out against organisations and institutions that were dedicated to providing care for some of our most vulnerable fellow citizens. It argues powerfully that it can be a false economy to ignore the wealth of accumulated practice-based evidence and to offer, by contrast, so-called evidence-based, technical-rational packages of treatment under the guise of improving access to psychological therapies.

This volume is in the form of a series of psycho-social and ‘groupish’ associations to the theme of the therapeutic milieu under fire. The approach is trans-disciplinary and it offers spaces for conversations between service-users, nurses, social therapists, project workers, housing support workers, probation officers, psychiatrists, social workers, group analysts, psychologists, psychotherapists, managers, civil servants, educators, researchers and the general public (among others) about the changing and complex relationship between troubled individuals and their troubling social, organisational and institutional context.

The contributors all work on the ‘frontline’ in one way or another, many working with marginalised and excluded outsiders at the edges of our exclusive society. This book explores the ways in which these outsiders are offended against and how, in turn, they offend against others, within systems designed both to care for and to contain them. What is the task of the professional caring for a mentally disordered offender? How can they offer security without custody, or care without collusion or detachment? When does ‘care’ become a perversion of ‘control’? Why is thought replaced with action and why might it be so hard for the milieu to replace action with thought? These are some of the central questions that were debated in our one-day seminars, and whose dynamics are explored in this text.

In presenting this range of papers, and the multiple complexities that these authors explore, we hope to enable the reader to come to a better understanding of the ways in which the therapeutic milieu comes under fire from without and within, so that we can think together about how to remain thoughtful and committed to the task while anticipating and responding to these inevitable attacks.

Thinking under fire is essential in this work, and so too is reconstructing our internal and external milieu. The systems-psychodynamic thinking of the International Association for Forensic Psychotherapy and the therapeutic community model combine in contemporary practice to give us a model of the conscious and unconscious processes that inform criminal acting out or the expression of personality disorder: a model that helps us to make sense both of the violence in the patients and the violence in the societal response.

Copyright © Jessica Kingsley Publishers 2012.

6 Myths about Panic Attacks – by former panic sufferer, Dr. Sandra Scheinbaum

By Dr. Sandra Scheinbaum, a licensed clinical psychologist, board-certified senior fellow in biofeedback, certified yoga instructor, nutrition coach, and the Director of Feed Your Mind Wellness Programs. A former panic sufferer, Dr. Scheinbaum has practiced mind-body medicine for over 30 years, successfully teaching hundreds of clients to overcome panic.

She is the author of the new book, How to Give Clients the Skills to Stop Panic Attacks. Here, she shares some common myths* about panic attacks.


Don’t Forget about the Myths

Along with a hopeful message regarding recovery, it’s important to address the myths surrounding panic. A panic episode may be frightening, but it’s not dangerous. Use the myth-busters below as needed.

Myth #1: Panic Can Cause a Heart Attack, Heart Failure , or Cardiac Arrest.
If you have heart disease, an electrocardiogram (EKG) detects noticeable electrical changes. During a panic attack, your heart beats faster. That’s all.

Myth #2: Panic Leads to Cessation of Breathing or Suffocation.
A panic attack will not cause you to stop breathing or suffocate. Under stress, chest and neck muscles tighten, which limits breathing capacity. But don’t worry, the brain has a built-in reflex mechanism that forces you to breathe if you’re not getting enough oxygen. You’ll automatically gasp and take a deep breath long before reaching the point where you could pass out from a lack of oxygen. Even if you did pass out, you would immediately start breathing again.

Myth #3: Panic Leads to Fainting.
You may be feeling light-headed because blood circulation to the brain is reduced, but a panic attack won’t cause you to faint.

Myth #4: Panic Causes Loss of Balance and Falls.
A panic attack may cause you to feel dizzy because the stress response may be affecting the inner ear. But panic cannot cause you to lose your balance. I understand you feel “weak in the knees.” That’s because the adrenaline surging through your body causes blood to accumulate in your leg muscles. The good news is the legs don’t lose strength, and you won’t fall over or be unable to walk.

Myth #5: Panic Means I’m “Going Crazy”.
You’re breathing quickly during a panic attack, which reduces blood supply to the brain and causes constriction of blood vessels. The result: feeling disoriented. Although it certainly feels like an out-of-body experience, you can’t “go crazy” during a panic attack or have what used to be referred to as a “nervous breakdown.” In fact, you’re perfectly capable of thinking and functioning normally because these sensations are meant to protect you. There’s no evidence that psychotic conditions, such as schizophrenia, stem from panic attacks. We don’t see visions, hear voices, or become delusional during a panic attack.

Myth #6: Panic Leads to Loss of Control.
A panic attack won’t cause you to “lose control” or act in a bizarre way. You won’t burst out screaming or harm yourself. It may seem as if you’re “losing it,” but the opposite occurs: all senses reach a heightened state of alertness in order to protect you.


*Adapted from Chapter 1: Could This Be Panic?

For information, tools and exercises about how you can help clients prevent and abort panic attacks through lifestyle change and mind-body relaxation, pick up a copy of How to Give Clients the Skills to Stop Panic Attacks or check out Dr. Scheinbaum’s website.

Copyright © Jessica Kingsley Publishers 2012.

‘Without a life story, a child is adrift, disconnected and vulnerable’ – Dr Bruce Perry on the value and power of the Life Story approach

By Dr Bruce Perry, adapted from the Foreword to the new book, Life Story Therapy with Traumatized Children, by Richard Rose.


A fundamental and permeating strength of humankind is the capacity to form and maintain relationships – the capacity to belong. It is in the context of our clan, community and culture that we are born and raised. The brain-mediated set of complex capacities that allow one human to connect to another form the very basis for survival and has led to the ‘success’ of our species on this planet. Without others or without belonging, no individual could survive or thrive. This need is so biologically powerful that when an infant is given signals from his caregivers that he is ‘not wanted’ and does not belong, the brain’s neural networks will activate a ‘shut down’ response and induce a ‘failure to thrive.’ And even with calories (but without the physical manifestations of ‘love’) this infant will lose weight and may die. This early life manifestation of the power of belonging has many related neurophysiological features later in life; the stress response and ‘reward’ networks in our brain are all interwoven with our ‘relational’ neurobiology. When familiar and welcoming human interactions are present, we feel pleasure and safety; we are regulated, we belong. When we are disconnected, when we are marginalized, we feel distressed, we literally feel pain.

This powerful, regulating, rewarding quality of belonging to a group, a family, a community and culture is not just focused on the present. We each feel a need to be connected to the people of our past; and without being able to draw on this connection – this narrative – it is almost impossible to envision hopes and dreams for a connected and safe future. It is the very part of our brain that is most uniquely human, the neocortex, that allows us to store, sort and recall our past as we construct the narrative that becomes the pathway from the past, and it is also the neocortex that envisions our pathways into the future. The neocortex allows humans to tell time; to create complex symbolic representations and associations that we have transformed into various forms of language; in music, art, writing (all inventions of our past) we are able to re-tell our story. The story of our people, where we come from and how we belong; our cortex helps us process, sort and sequence events and to store both our personal experience and the narrated experiences of others; the story of our parents; our parent’s story of our childhood before we could make narrative memory; the story of their parents; the history of how we belong.

Story telling is a unique and permeating quality present in all cultures across every era. The first and universal function of narrative in song, ceremony and story is how we have come to be, where we are connected, where we belong, where the connections were broken, lost, repaired. And in the cortically mediated narrative of storytelling of how we belong and how we have come to this point comes a powerful regulating, anchoring, reassuring and rewarding neurophysiological effect. It is no surprise that humans, the storytelling primates, are fascinated by narrative, poetry, novels and movies. The majority of our arts will portray personal narrative in some fashion.

This crucial aspect of the human condition – belonging, knowing your narrative – is damaged for many. And damaging the narrative of a people (cultural genocide) is at the core of a destructive, transgenerational process that has many negative manifestations; as odd as this may sound, the neurobiological consequences of stripping a community or culture of their language, customs, religious beliefs or child-rearing practices are devastating. The individual stress response systems and ‘reward’ neurobiology in a marginalized, disconnected and culturally fragmented group will be compromised and predisposes individuals of that group to a host of mental (e.g., depression, suicide), physical (e.g., diabetes) and social (e.g., increased substance abuse) problems. This is seen in Aboriginal communities in Australia, First Nations communities in Canada and Māori communities in New Zealand, among others. The neurobiological consequences of the destruction of narrative for a people are devastating.

It is the same with individual maltreated children. A fragmented, damaged, discontinuous personal narrative puts an individual child at risk. A child that is lost within her own family, community and culture is neurodevelopmentally vulnerable. Without a life story, a child is adrift, disconnected and vulnerable – their neurobiology of reward, stress regulation and relational interactions are all altered – in negative ways – without a cortically mediated coherent personal narrative. Our conventional efforts to ‘treat’ them will often be frustrated and ineffective. Sadly, most mental health interventions with maltreated children do not pay any attention to the child’s story. The focus is the manifestation of pathology – the symptoms. Make Billy stop swearing, hitting, running away – make Billy pay attention, be respectful, comply. We lose sight of how disconnected Billy is and often we actually contribute to the fragmentation and disconnection of his life story – a brief but telling story to illustrate how our efforts to ‘protect’ maltreated children can add to their confusion and disconnection. We often make these children worse.

At the beginning of an evaluation of a ten-year-old boy in foster care at our ChildTrauma Academy clinic, I asked him his name:

‘Which name do you want to know?’

‘What do you mean?’

‘Well, I don’t know my name, I guess. My new mum calls me Thomas. My last mum called me Leon. And when I visit my grandmother she calls me Robbie.’

‘What name do you tell your friends to call you?’

‘I don’t have any friends at this new house.’

‘Do you know what your biological mother named you?’

‘I think she named me Baby.’

As I looked through the records I could see that he was born a few weeks early. He had been in the Pediatric ICU and had never been named by his mother. His discharge records stated: ‘Baby Boy Jones’. Ten placements and four ‘names’ meant he was disconnected and adrift with no personal narrative. But ‘fix him’ if he acts out. He is inattentive, disrespectful, struggles in school and won’t do as he’s told. Fix him. Find the right label. Give him the right drug. Our current approach to these maltreated children has lost sight of the essential element of healing – and that is reconnection. Connect to the present and increase the number and quality of relational opportunities but, as important, reconstruct your past connections, lay out your disconnects and clarify your personal journey to the present.

A life story approach such as that described in Richard Rose’s new book Life Story Therapy with Traumatized Children helps children to reconnect by reconstructing their personal narratives, echoing the fundamental storytelling powers known to our ancestors who incorporated storytelling into all of their healing practices and rituals. In other words, storytelling therapy reflects not just knowledge of human healing; it is a manifestation of wisdom about humankind. The value and power of the life story approach, which is both developmentally sensitive and ‘trauma-informed’, cannot be underestimated. For any clinician working with our most disconnected children it is a wonderful way to help them reconnect – and heal.

Dr Bruce Perry, MD, PhD
Senior Fellow, The ChildTrauma Academy, Houston, TX
Adjunct Professor, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University , Chicago, IL

Copyright © Jessica Kingsley Publishers 2012.

Where is mental health diagnosis heading, and where does the DSM IV fall short?

In this article, Dr. Peter Ladd, co-author of the new book, Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients, asks some important questions relating to traditional mental health diagnosis, and shares his own thoughts about where he believes it is heading in the future.


Does the Semantics found in the DSM IV Create a Problem for Clients?

The DSM IV is sophisticated in basing diagnosis in mental health on statistical probability. The Client Empowerment Model of diagnosis in mental health found in Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients, (Ladd & Churchill 2012) is sophisticated in presenting a holistic perspective. The lack of a holistic perspective found in the DSM IV may be partially attributed to the semantics found in it. For example, the DSM IV has such labels as Bi-Polar Disorder or Obsessive/Compulsive Disorder. Semantically, a person may incorrectly say, “I am bi-polar or I am obsessive/compulsive.”

From a strictly medical model, such semantics do not make sense. In medicine one does not say, I am cancer or I am stroke. However, with some mental disorders one can personalize them as though they were connected to one’s identity. A client empowerment model does not focus on labels but on patterns. For example, a person might say, “I have a pattern of bi-polar disorder or I have a pattern of obsessive/compulsive disorder. These statements are not connected to one’s identity. They are accurate semantic statements of a pattern they are in. Such unsophistication in DSM IV labels may lead to increasing the severity of disorders rather than reducing them. Most clients do not find meaning in statistically formulated symptoms but in understanding the semantically formulated patterns of their disorders. For example, if you asked someone, “Tell me who you are?” A person would not add up all of his or her negative symptoms and produce a label of how they see themselves. Most likely they would point out those characteristics that describe their unique way of being in this world. This means that it may be important in diagnosis in mental health to significantly separate a person’s mental disorder label from their identity.

The DSM IV is not sophisticated enough to achieve this function. A Client Empowerment Model of Diagnosis presents a client with a diagnostic pattern that specifically changes the discussion away from one’s identity to a pattern of experience that a person is going through. In practice, using a system that statistically categorizes mental disorders based on empirical probability has an explicit advantage for insurance companies, pharmaceutical companies and for the mental health practitioner yet such sophistication may be detrimental to clients, if these mental disorders are not presented in a more sophisticated, holistic and collaborative manner. Perceptually, clients may confuse the mental disorder label with their identity. The question to be asked may be, “Do we have a responsibility as mental health practitioners to diagnose in a manner where diagnosis is beneficial for all involved?”

The Direction of Clinical Diagnosis in Mental Health

Mental health practitioners have a responsibility or at least a professional mandate to include tests instruments within a clinical diagnosis. Some of these instruments are; mental status exams, objective testing, personality testing, motivational interviewing, behavioral, emotional and environmental testing.

However, the most noted test instrument used by mental health practitioners has to be the Diagnostic and Statistical Manual of Mental Disorders or more commonly referred to as the DSM IV (APA, 2000). This book is mostly a standardized classifications system so that all mental health professionals are speaking the same language. This manual breaks down into; Axis I – clinical mental disorders, Axis II – personality disorders, Axis III – medical conditions relating to mental disorders, Axis IV – psychosocial events and environmental concerns and Axis V a global assessment of a client’s ability to function.

Neuroscience may be on the verge of giving the DSM IV an alternative perceptual view of diagnosis with such instruments as; PET scans, MRI’s, and CT.’s and Mindfulness Research (Plante, 2011). However, such neurological research is limited to the laboratory setting without some form of phenomenological thinking. Neuroscience has stirred up a renewed interest in phenomenology or the study of experience (Siegel, 2010). In other words, human experience causes neurological changes, and neurological changes are best understood through studying human experience. Such a notion takes mental health diagnosis in a different direction than the DSM IV that adds up symptoms in order to give a diagnosis based on statistical probability.

From the consideration of a new neurological/phenomenological perspective brings rise to this question, “Are the only accurate mental disorder diagnoses made by adding up symptoms from the DSM IV, in order to render a diagnosis?” At this point, it is only fair to mention that such a question is not completely answerable, yet it does give possible direction to the future of diagnosis in mental health.

However, such a question does reflect the sentiments of those mental health practitioners and neuroscientists that are finding a need for each other’s information. Furthermore, it may raise questions as to the direction of psychological diagnosis from a strictly medical model, statistical probability perspective. Should psychological diagnosis rely only on a statistical probability of symptoms, leading to a diagnosis? Or, should we rely on neuroscience research and combine it with phenomenological experience in developing a more bio/psycho/social/spiritual (Holistic and Person-Centered) model of diagnosis? This may be the moment to consider a different model of diagnosis with the ultimate release of the DSM V, and the book, Person-Centered Diagnosis and Treatment in Mental Health: A Model for Empowering Clients is one attempt at presenting a different model.

Peter D. Ladd
May 2012

American Psychiatric Association. (2000) Diagnostic and statistical manual of mental health disorders (4th ed.). Washington DC: Author (Original work published 1952).

Ladd, P. & Churchill, A. (2012) Person-Centered diagnosis and treatment: A model for empowering clients. London, UK: Jessica Kingsley Publishers.

Plante, T.G. (2011). Contemporary clinical psychology (3rd ed.). Hobaken, NJ: John Wiley & Sons.

Siegel, D.J. (2010) The Mindful therapist: A clinician’s guide to mindsight and neural integration. New York, NY: W. W. Norton and Company.

Copyright © Jessica Kingsley Publishers 2012.

Life Story Therapy: Externalising feelings and perceptions through a chronological process

Richard Rose, child trauma intervention specialist and author of Life Story Therapy with Traumatized Children: A Model for Practice, shares some of his experiences of using life story work with traumatised children.


The unique concept of the life story approach is that it has a defined process:

The beginning (stage 1) requires the Therapeutic Worker to detect the past, to collate the stories of those around the child and to collect tangible items, such as first shoes, first books, cultural and religious material (e.g. Christening, Confirmation, Bar or Bat Mitzvah);

The middle (stage 2) provides the opportunity for the child to externalise their feelings and perceptions through a chronological process. To explore, challenge and conclude to the point that they can reframe their understanding and internalise their sense of self;

The end (stage 3) is the production of the book, the record of all that has been produced by the child, their carer and their Therapeutic Worker. The book becomes the history of the child and concludes with their hopes and desires for the future.

In short, all good stories have a beginning, middle and an end – therefore all narratives have a similar structure, time limited, focused and achievable. The child understands the sequence of discussion and can be helped to make sense of the past, present and plan for the future.

This second book uses case studies to illustrate the various exercises available to the life story Therapeutic Worker. It also details case studies and tools that might be useful to all those working within the social care and education fields. Although the case studies are short, I hope that they illustrate how useful such activities prove to be in communicating with traumatised children. I have considered attachment and trauma, their effect on the brain and on the development of the child, and have used case examples to explore these crucial areas.

One young person I worked with did not want to talk about the things that upset her. She was resistant to the idea of life story, but through the Jenga and Family Tree exercises (discussed more in my book), she was able to engage in play which required her to share information about her likes, dislikes, worries and hopes. By the third session, this young person stated, ‘I am ready now.’ From then on she produce thoughtful, insightful and distressing perceptions. As she talked these out – externalising them – she was able to illustrate her life and understanding on ‘wallpaper’ and, towards the end of the work, reframed her sense of self and internalised healthier thoughts of herself and those around her.

I also worked with an angry primary school child who had been hurt by everyone who had had previous ‘care’ of him. He was alert, poised and preoccupied with possibilities of hurt, either by me or his carer or by himself. There is still debate about re-traumatising children by visiting the past, and there is a possibility of this if the Therapeutic Worker is unsure, impatient, too patient, etc. By using memory boxes, fact/fiction/fantasy and heroism models, he was able to work through his anger and his pain. We used the Behaviour Tree to do the same by thinking about the source of his behaviour, the actions of those in his past and the consequences for those in his present and future.

I hope that by reading my new book, people will be able to use the examples of practice in their work with children. I trust that some readers will want to learn more about the positive outcomes for children who undertake life story, and how, if we can unlock the child’s past, we can release their potential for the future and help carers deal with the present. I am honored that Dr Bruce Perry has written a foreword to my book and have found his interest in my work both supportive and inspiring.

Copyright © Jessica Kingsley Publishers 2012.