With eating disorders and action therapy, slow is the way to go

JKP author Karen Carnabucci, a licensed clinical social worker and board-certified trainer, educator and practitioner of psychodrama, sociometry and group psychotherapy, discusses pacing of eating disorders and actions therapies workshops and training sessions for clients—With eating disorders and action therapy, slow is the way to go. Karen is the co-author of Healing Eating Disorders with Psychodrama and Other Action Methods: Beyond the Silence and the Fury.

When we work with people with eating disorders and dieting struggles, we suggest going slow—very slow.

Some of our clients, trainees and others are surprised about the pacing of our workshops and training sessions where we encourage meditative Healing Eating Disorders with Psychodrama and Other Action Methodsbreathing, mindful movement, frequent pausing during meals and dramas that proceed step by step and scene by scene. After all, psychodrama is supposed to be “dramatic” with lots of lively action—right?

Although it is true that psychodrama has sometimes been labeled with a reputation for a rat-a-tat style of dramatic scenes – which certainly can be useful in dramas that focus on play or take place in educational and theater settings – such a speedy pace is not always helpful for eating disorders treatment.  

In the case of eating disorders, slow is the way to go. In our book Healing Eating Disorders with Psychodrama and Other Action Methods: Beyond the Silence and the Fury, we encourage thoughtful pacing as we seek to model to our clients another option for living.

Here is why:

  • Our culture favors a certain kind of body shape and weight and level of attractiveness that is not realistic for most people to meet. This same culture promotes quick fixes and fast food at the expense of learning how to savor food, the experience of eating and the process of living. Women are encouraged to try faster dieting techniques for losing weight—28 pounds in 30 days!—and men are given quick-time promises for products and gadgets to bulk up their muscles or carve those abdominals. Being able to invest time in recovery can be an important relief for our clients who may have felt pushed and pressured most of their lives to look a certain way. When we take our time, recovery becomes not a wild race to the finish line but a slowly evolving process as the person learns to improvise new ways of responding to life’s challenges.
  •  The natural rhythms of the body have been greatly disrupted by disordered eating.  Appetites are skewed for high or low, and the sleep cycle is often disrupted along with other basic body functions. All body systems—circulation, respiration, digestion and elimination plus the reproductive system, endocrine system and the nervous system—have subtle rhythms of their own, and we must give permission to our bodies to learn how to return to these natural rhythms. Experiencing moments of slowness with meditative walking, quiet reflection, gentle yoga poses and periods of listening interspersed by periods of action are a few of the many ways to support and integrate the experience of slowing down.
  • People with eating disorders and body distress are likely to have a history of trauma, whether it is sexual abuse, childhood maltreatment, early disruptions in attachment to caregivers, such as separation from mother due to premature birth, early illness, death of mother, and intergenerational pain. When we encounter trauma as professionals we must be careful that we do not rush our clients into re-experiencing the trauma bare of strengths and resources. We like the Therapeutic Spiral Model, a modification of psychodrama for trauma survivors, which focuses on identifying and integrating personal, relational and spiritual strengths before trauma material is addressed. As the person actually experiences these strengths and resources, he or she will be able to consciously and effectively address the trauma in a manner that leads to genuine healing.

Of course, there are times when our dramas with eating disorder clients became raucous with laughter and cheers, and there may be singing and drumming or stomping of feet when the client, the drama and the developmental stage of the group properly calls for these experiences. The skilled psychodramatist will be able to move between all of these scenes and experiences to guide the client to a new life.

Celebrating the launch of ‘Forensic Music Therapy’

Forensic Music TherapyJKP were delighted to attend the launch of Forensic Music Therapy: A Treatment for Men and Women in Secure Hospital Settings on Friday 25th January at the stunning Burgh House in Hampstead, London.

Hosted by the three editors of the book, Stella Compton Dickinson, Helen Odell-Miller and John Adlam, and attended by many of those who had authored individual chapters, the evening brought together not only music therapists, but many professional musicians, psychiatrists, psychotherapists and other mental health professionals. We were treated to an evening of beautiful music by the Henry Lowther Quartet followed by two solo oboe recitals. The editors, and Dr. Gill McGauley, Consultant Psychiatrist at Broadmoor Hospital, spoke about the ground-breaking work that the book sheds light on, and the proven effectiveness of music therapy with those in secure settings, especially in encouraging feelings of empathy. They also spoke about the rarity of being able to obtain informed consent for case studies involving high security offenders, another factor which makes this book unique.

Click below to see a video of Stella Compton Dickinson’s speech at the celebratory evening:



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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.


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.


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.


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


Understanding Adult Survivors of Domestic Violence in Childhood: Still forgotten, still hurting

JKP authors Gill Hague, Ann Harvey and Kathy Willis explain why their new book Understanding Adult Survivors of Domestic Violence in Childhood: Still forgotten, still hurting begins the task of breaking the silence on this previously neglected subject. They introduce the book and it’s contents including an extract from the poem Arms Outstretched to Them.

This new book is about people who experienced domestic violence between their parents or carers, when they were children, and about the impacts these experiences have had on them into adulthood, which have in many cases been scarring and painful.

There is little research regarding adults with experiences and memories of childhood domestic abuse, but the book looks at what studies do exist and at what we can learn from them. It also looks at the more prolific research which has been conducted about children themselves experiencing domestic violence, as this research can sometimes offer insights for what might happen when the person concerned grows up.

The book goes on to discuss practice, services and policy issues. The idea is that it will be useful to helping professionals, to agencies and to people with this personal history. It also considers recovery techniques including counselling and therapy.  It is written in a relatively non-academic and accessible way, whilst remaining academically rigorous.  We hope it will be use to adult survivors of domestic violence, to students of social work and the social sciences, to academics, to violence against women researchers, and to practitioners, policy-makers, social workers and counsellors.

This issue is one which has been little explored.  Hence the subtitle of the book, a version of which was the authors working title: “Still Hurting, Still Forgotten”.  Many who carry memories and traumas of domestic violence from childhood do indeed feel both; that they are still hurting long after the events themselves occurred, and that their plight is one which has been largely forgotten, overlooked and ignored. This book attempts to open up this previously neglected subject as a new area for further research and practice.  We are pleased that readers to date have identified the book to be a pioneering one which breaks new ground.

It has an unusual structure in that it also includes creative and personal writing, interwoven with the material for professionals, counsellors, social workers, students, survivors themselves and researchers. Most importantly, it includes a series of moving and powerful poems and personal testimonies, specifically produced for the book by adult survivors of childhood domestic abuse. One poem by a middle-aged Scottish women talks about how long the painful impacts of experiencing childhood domestic violence can endure.  Her words might have resonance for others reading the book.  She says that:

  She couldn’t help remembering,
       even though she’s well past 50,

       The feeling of the shades coming down.

       Her father mad with fury.
       But she couldn’t stop it,
       couldn’t stop him.
       Crying and sobbing,
       tears dripping off her chin.
       She couldn’t stop him.

       She couldn’t help remembering.

       And she learned not to sleep.
       She dreaded anyone suspecting.
       She couldn’t help remembering.
       Her expectant young life reduced to
       what felt like fragments
       and a tangled feeling.

       She couldn’t help remembering.

       Even though she’s well past 50. 
       But she couldn’t stop it,       
       crying and sobbing,
       arms outstretched to them.
       Even though she’s well past 50.

A final note from Gill Hague:

This is the last and closing book of my career and I am proud of it. The final words of the last poem are: “It is finished.  It is over”.  They apply to the individual poem, to the poet’s personal recovery, to the book itself, and to my own career and 40 year journey working on violence against women issues. I trust that this final book will be of use in the field to both practitioners and researchers, as well as to people themselves who carry life experiences of domestic violence in childhood.

VIDEO: Rudy Simone’s 22 Things a Woman with Asperger’s Syndrome Wants Her Partner to Know

Rudy Simone is on a mission to prevent AS/non-spectrum relationships from breaking down because of a lack of information. Check out this video to find out more and for a great overview of her latest JKP book, 22 Things a Woman with Asperger’s Syndrome Wants Her Partner to Know.

In her latest book, Aspergirls author Rudy Simone covers 22 common areas of confusion for someone dating a female with AS and includes advice from her own experience and from other partners in real relationships. She talks with humour and honesty about the quirks and sensitivities that you may come across when getting to know your partner. All the pivotal relationship landmarks are discussed, including the first date, sex, and even having children.

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.

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.

20 years and 5 editions: The evolution of ‘The Psychology of Ageing’

By Ian Stuart-Hamilton, Professor of Developmental Psychology and Faculty Head of Research at University of Glamorgan, Wales, and author of The Psychology of Ageing, now in its fifth edition.

This sounds like a typically tedious middle-class academic’s remark, but the truth is that this book’s life started at a drinks party at Cambridge University. In 1991 I was attending a conference and was asked by a publisher’s rep if I’d like some more of the warm liebfraumilch, and by the way, did I have any ideas for new books? I have a dim record of the ensuing conversation and a vague memory of giving her my address before going into the traditional conference dinner of rubber chicken. A few days later, a letter arrived from Jessica Kingsley asking me to submit a more detailed outline with a view to publication. The rest, as the cliché says, is history.

Thus, more than two decades later, the fifth edition of The Psychology of Ageing: An Introduction is to be launched on the world.

Request an e-Inspection copy!

The significant changes in the new edition can be summarised as follows. First, it is a lot bigger – about a third larger in size than the previous edition. This is in part because of the new chapter (of which more below), but also because nearly all the chapters have been considerably expanded to take account of the growth in the research literature over the recent past. In part this is a matter of updating what new things have been found within an existing area of study. However, new fields of research are now opening up, and these require critical coverage. For example, the greater availability of brain scanning equipment means that studies of neuropsychology are becoming commonplace, particularly in intelligence and memory. Although these have been mentioned in previous editions, this time the topics are given far greater prominence.

Within chapters, topics are broken down into reasonably bite-sized portions, each of which can typically be read without having to read too much of the preceding text. I am, however, aware that a lot of readers will not have an extensive (or indeed any) background in psychology, so I have included a few explanatory notes (that more experienced readers can easily skip over) or in the case of longer explanations, appendices (e.g. describing basic anatomy of the brain and how nerves communicate with each other). I firmly believe that if you can understand a science documentary on television, you should have no conceptual difficulties in reading this book.

Before this deters any academic readers thinking that this is a lightweight book – it isn’t. For students (undergraduate and postgraduate), lecturers and academics in cognizant disciplines, this will serve as (I hope) a respectable primer in the field – the challenge for these readers is what they do with the knowledge in forming their own, more detailed studies.

I mentioned earlier that there was a new chapter – this is on Death, Dying and Bereavement. I have previously resisted including this chapter, not because of any aversion to the subject, but because researchers are divided on whether the topics should be considered as part of ageing, or should be regarded as a separate discipline. In this edition, I have decided to include a chapter. It covers the key issues of the processes of dying (including a critique of Kubler-Ross’s theory), differences in approaches to death and dying, etc. In short, the key psychological topics are covered. I have avoided straying into what I see as being the preserve of sociology and history (e.g. cultural differences in funeral rites and similar) to keep the psychological flavour of the book undiluted.

However, not all has changed. The glossary of technical terms has been saved, the writing style is (I hope) not all that drastically different, and I have tried to keep the level of explanation the same as in previous editions. These are the things that critics have liked about my earlier books, and I am not about to start biting the hand that has stroked my fur so nicely over the years.

Anyway, I hope you enjoy the book. I am currently writing another one for Jessica Kingsley, which will be out at some point in the future, probably dependent upon when my parrot permits me to type without pestering for food.

Ian Stuart-Hamilton

Copyright © Jessica Kingsley Publishers 2012.

“Suicide is not a problem that can be tackled alone – but it can be tackled.” – An Interview with David Aldridge and Sergio Pérez Barrero

David Aldridge is co-director at the Nordoff-Robbins Zentrum in Witten, Germany, where he specializes in research methods for various therapeutic initiatives, including music therapy. He is the author of a wide range of JKP books on topics ranging from music therapy and dementia to non-violent resistence in families and spirituality in health care.

Sergio Andres Pérez Barrero is a doctor of medicine and a professor of psychiatry specializing in suicidal behaviour, particularly from a family and community perspective. He has been temporary advisor of the Panamerican Health Organization and World Health Organization for the suicide prevention in The Americas Region, and is the author of many books about the theme of suicide.

In this interview, they discuss their collaboration on the new book, Understanding Suicide: A Guide for Families and Professionals, and their interdisciplinary approach to suicide prevention. 

Please tell us about your professional backgrounds – how did you become interested in this area?

David: What started me off studying suicide was when I worked for a voluntary organization, the Samaritans. Although I had spoken with suicidal people through the night, there were still others who were in hospital the next day. We seemed to be missing something. I wanted to know what this was. Then I met a professor of psychiatry who told me that suicide was an act that just came “out of the blue” and could not be prevented. From my limited experience at that time, I knew it just could not be true. As a social worker and youth worker, I knew people who had become suicidal over time and could see the process of their worsening plight.

I began my research career with a doctoral study of suicidal behaviour where I developed a model of escalating distress in family situations. I was one of the early doctoral students with the Open University and they encouraged my study because of the relevance and applicability that it has for the community.

Sergio: I was the author of the first book on the subject written in Cuba during the revolutionary period, which was called Suicide: Behavior and Prevention and published in 1995. In the same year, I founded the Suicidology Section of the Cuban Society of Psychiatry, and was Chairman of the Organizing Committee of the country’s first and only congress on the Prevention of Self-destructive Behavior in November 2003, which was attended by delegates from Cuba, Norway, Puerto Rico, Mexico and Argentina.

I continue to give lectures on community projects and concentrate on psychiatric care in primary health care.

What led you to collaborate on this book?

David: We are both interested in a systemic perspective on suicidal behaviour and have emphasized an interdisciplinary approach in our writings. In our working lives we are committed to the relief of personal distress. However, we know that this distress has relational, cultural and social origins.

In addition, we are both concerned about the world-wide problems that suicide causes, particularly in developing countries, and we believe that an inter-disciplinary approach to prevention is necessary.

Both of us are also committed to the idea that scientists from all over the world should be able to share their knowledge freely, without embargoes of any kind. Suicide is an international problem that requires our combined efforts including free access to research findings and clinical expertise.

Can you give us an overview of the book – what is it about?

David: Suicide is about a process of distress that worsens. Finding the causes of that distress and offering an alternative means of distress management will help prevent suicide.

Many professionals come into contact with people who are in distress. Teachers come across bullying all too often. They also meet children who are having family difficulties where parents have mental health problems, problems with substance abuse, are having difficulties coping with a chronic illness or are in financial difficulties. Some children face despair when their family lives fall apart. Social workers and probation officers, too, meet these problems in their daily working lives. Health professionals are often faced with emergency crises which they know are only the tip of an iceberg of distress. This book shows some of the warning signs and encourages them to see the bigger picture and intervene earlier.

Sergio: The book aims to bring awareness to those concerned with suicide prevention, whether students, professionals or those interested in preventable death more generally. It was written in a accessible, digestible way for the average reader, starting from the principle that suicide prevention is the responsibility of whomever is closest to the suicidal person and knows how to help.

Our aim in the book is to simplify how we approach suicidal behaviour. Because there is so much research from varying perspectives, and the problem is multi-faceted, it is possible to make things very complicated. If, however, we look at the chain of events where distress in the family becomes suicidal behaviour that needs a psychiatrist, then we can bring some clarity. Differing perspectives on the problem are important. What we are emphasizing is the process of events for the person and his or her family so that they are clear to see.

What are some obstacles that professionals encounter when working with suicidal individuals and their families?

David: One of the main obstacles that we encounter is the shame and stigma surrounding mental health, and feeling suicidal in particular – both from the sufferer’s point of view and from the health professional’s viewpoint.

The second obstacle is that many general health care practitioners do not recognize depression often, or early, enough.

The third problem is the lack of cooperation between health care practitioners, social workers and care agencies.

The fourth problem is that of economic decline. At the moment we are writing this book, Greece has been facing a major economic challenge. The suicide rate has risen in this time by 40%.

What we offer is a model to show how problems escalate and how these problems are connected to relational contexts. We are encouraging people, particularly professionals, to communicate with each other and to look at the bigger picture. This is not a problem that can be tackled alone – but it can be tackled. To do so, we have to talk to each other. As professionals, we also need to collaborate more on combating mental health problems. This is an educational process, heightening awareness of how depression manifests itself but also removing the stigma of mental health.

Sergio: In my view, the biggest issue is that the suicidal do not come forward to receive specialist attention. When they do seek help, though, the obstacles are recognized by an expert on the subject, among which are the following:

  • Difficulties on the part of the family to interpret suicidal signals;
  • The persistence of myths around suicide that we must try to eliminate;
  • Failure of family members to take the necessary measures to keep their loved one alive – for example, allowing access to suicide methods and leaving them alone.

Why was it important to include a chapter on the internet?

Sergio: Bullying, in all its manifestations, is a major health problem in school settings. Cyberbullying is more common in developed countries in which adolescents and youth have access to the internet, email and other technologies, while face-to-face harassment was much more common in our day.

David: The internet is an important means of gaining information in modern times. It also provides the platform for various social networking sites, which can also be anti-social in that they are sometimes used for cyberbullying. Bullying is a primary cause for distress in young people.

It is important first to raise awareness about cyberbullying and about the fact that this can bring young people to a state of despair. Second, parents need to understand that while their children do indeed have private lives, that privacy can also mask a social threat to their well-being and mental health. What may be an innocuous social network can become the source of a malevolent attack from which a child has seemingly few avenues of escape. The social can circumvent closed doors into the very heart of privacy, beyond the caregiver’s knowledge.

What are some of the most important messages that you hope the reader will take away from this book?


  • The need to implement national and regional strategies for suicide prevention using a multi-layered approach involving voluntary, educational, social and health care resources.
  • The need to resolve distress early using a family approach.
  • The need to be active in preventing bullying.

Copyright © Jessica Kingsley Publishers 2012.

Breaking the intergenerational cycle of insecure attachment in families of African Caribbean Origin

Elaine Arnold is Director of The Separation and Reunion Forum, UK, an organization dedicated to highlighting the traumatic effects of broken attachments, separation and loss. Elaine has previously worked as a teacher, lecturer, child care worker, counsellor and psychiatric social worker. Her interest in attachment issues and separation was first sparked in the late 1940s when teaching in a school in a children’s home in Trinidad and Tobago, which housed children for a number of reasons including the emigration of parents.

Here she talks about her new book, Working with Families of African Caribbean Origin: Understanding Issues around Immigration and Attachment, which looks at the importance of understanding the intergenerational impact of immigration on attachment for families of the African Caribbean diaspora.

The subject of this book is linked to the African Caribbean experience of slavery and, later, migration to Britain to work and help rebuild the country after World War II. Can you paint us a picture of what happened, and the impact this had on the family life of African Caribbean people who migrated?

The book begins with a brief historical account of African slavery in the Caribbean, in order to put the people who were formerly called West Indians, but now called African Caribbeans, into context.

Transatlantic slavery by European slave owners and African slaves shaped the Caribbean societies which were based not only on class and wealth, but on colour as well.

After the emancipation of the slaves, Society under the colonialists maintained the same societal structures and the majority of the black population found there were the poorly paid working class.

During the second World War, Britain could not afford the necessary development required on the islands of the Caribbean, and poverty was rife due to the high levels of unemployment. The situation then leant itself to large scale immigration. When Britain decided to recruit labour, there was no difficulty in finding people to migrate to Britain. The majority were from the rural areas who had no idea of life in Britain and, on arriving, found harsh conditions which for many reminded them of the harsh conditions of their enslaved ancestors. They were not physically abused, as their ancestors had been, but the psychological damage of broken attachments, separation and loss had a similar effect.

This book draws upon your own research and experience of working with African Caribbean families, and using attachment theory as an approach to understanding. Can you tell us how you first started to work in this area, the influence of Bowlby’s ideas and how this shaped your own career?

I was first attracted to how young children behaved when separated from their mothers and brought to a Children’s home. Young children who were cared for by a succession of carers soon developed very shallow relationships with any adult who would give them attention, and sometimes babies would fail to thrive.

When older children were given the opportunity to experience family life in surrogate families, they showed marked self-esteem and improvement in their educational attainment.

I studied the work of Dr John Bowlby, beginning with his seminal work on child care and the growth of love, and his continuing work with Mary Ainsworth which resulted in the formulation of Attachment Theory. This helped me to work with families and specifically mothers who had come to Britain during the early years of the immigration and who were finding it difficult to relate to their children who had reunited with them after being cared for by other members of the extended family in the Caribbean to whom they had become attached.

I then determined to raise awareness and understanding of how attachment develops among families which had the experience of separation and loss.

In 1999 you founded the Separation and Reunion Forum to to raise awareness of and to promote discussion on the importance of secure attachments of young children. Can you tell us about the Forum and its work?

In 1999, I interviewed a group of women about their experiences of having been left in the Caribbean with extended families for varying lengths of time before reuniting with their families here in the UK. It was remarkable that each woman felt that the problems in their relationships with their mothers were unique to them. They were relieved to hear that they were not alone. I explained the basic principles of attachment theory and they unanimously agreed that more meetings should be held and more African Caribbean families should be made aware of the phenomenon. Separation and Reunion Forum (SRF) was agreed as a working title, but the core group of eight women decided to keep it. Recently we have added a strap line: “Supporting Relationships and Families”.

The group also decided that a conference should be organised so that other people with similar experiences could be invited, as well as professionals who worked with African Caribbean families and who frequently misunderstood them. The first conference was held in 2000 and was entitled “The Unspoken Price of Immigration”. So successful was the conference that the participants requested another, and currently SRF is holding its 12th conference. Annual Conference reports are available. SRF keeps its attendance fees low and is particularly interested in attracting students going into helping professions as well as retired persons and lay persons. Speakers are very generous and most donate their time free to the organisation. Two universities, Goldsmith’s College and the London Metropolitan, have been generous in collaborating with SRF in planning the conferences and in providing accommodation.

SRF is a membership organisation opened to those have both personal and professional experience of issues arising from broken attachments, separation and loss and who are interested in discovering more about Attachment Theory. The organisation is funded only by membership fees, earnings from seminars and conferences, and run with the help of volunteers. In 2009, SRF applied for and obtained charitable status.

You can visit us online for more info: www.serefo.org.uk.

Do you think that helping professionals working today have a sufficient understanding of the experiences of African Caribbean families?

Unfortunately there are some members of the helping professions working with African Caribbean Families do not have a sufficient understanding of the experiences of these families. This lack may spring from the belief that we treat everyone the same and therefore the individual’s culture is not relevant. Some have not been taught history, including the colonisation of the Caribbean and the effects of the transgenerational effects of slavery and immigration. Some may consider that they themselves had had difficult experiences and have overcome them so Caribbean people should be able to overcome theirs. If the professionals are white, at times they are afraid of asking questions for fear of being thought to be racist, and sometimes still there is blatant discrimination against the black individual or families.

There persists a stereotype that African Caribbean fathers are uninvolved fathers, which you challenge in this book. Can you tell us about your own findings?

With all stereotypes, very often those who do not conform to them are overlooked. There are some men who do not settle into family life, and who engage in casual liaisons and leave the mothers of their children and the children unsupported. Many are young and unemployed, and there are some who may be exploitative of vulnerable women. Nevertheless, as with some of the women in my research who had very positive experiences with fathers, there are some fathers who sometimes were more understanding of them when they first arrived from the Caribbean.

Where do you see the impact of these family separations still continuing today?

The impact can be seen in young mothers who find difficulty in relating to children and in attachments that are not secure.

Recently I was told by a young mother that she was very matter of fact with her three year-old son as that is how her mother was with her. She went on to say that her mother had been left in the Caribbean and when she came to Britain her relationship was not good with her own mother. This insecure attachment has now been passed on to the third generation.

The intergenerational nature of poor attachment can be a unending cycle if there is no intervention to help bring understanding of it. Children whose educational attainment is low very often are avoidant of their teachers, as they are of parents with whom they do not have secure attachment, and so they pay little attention to the teacher or become disruptive which often leads to exclusion.

The book not only provides a fascinating insight into the lives of African Caribbean families living in the UK, but also features practical advice for professionals. Can you give some examples of the advice you give in the book?

  • In working with African Caribbean Families it is necessary to bear their immigration history in mind and, as Bowlby suggested, to provide a secure base where the individual of family is able to explore past painful experiences. This does not only imply the physical space but also the attitudes of the worker.
  • Provide the encouragement for individuals to reflect on their early experiences especially with parents and how these influence their present feelings.
  • Help children and adults to realise that some of the images of themselves or of others that they have experienced may not be appropriate for the present or the future.
  • Professionals need to accept that sometimes the experiences of their clients may trigger some of their own feelings about their unresolved experiences, and they may have difficulty in forming a relationship. This kind of self-reflection requires careful and sensitive supervision.

Copyright © Jessica Kingsley Publishers 2011.