Why helping traumatised children find the right words is so important.

Jane Evans, trauma parenting specialist and author of How Are You Feeling Today Baby Bear? writes about the importance of helping children who have experienced domestic abuse or other trauma to identify and talk about their feelings.

Early years children affected by domestic violence need help to find the words for their big feelings sooner rather than later.

Being able to recognise how we feel at any given moment is essential to our well-being, decision making and the way we relate to others and behave every day. Being able to understand and put into words our own feelings and those of others is also essential for our mental health and safety, never more so than when we are children. If a child can’t recognise the signs in their body of fear, anxiety, frustration, excitement and joy then they will struggle to tell the difference between them and this can make them vulnerable.

All illustrations by Laurence Jackson

All illustrations by Laurence Jackson

When it comes to children who have lived through domestic violence, or other trauma, matching words to their feelings and their bodily state, as early as possible, is even more vital. Post domestic violence, children need to be able to make some sense of the things they have seen, heard, felt, smelt, and even tasted. Without support to learn to do this, their emotional memories will remain unprocessed within them which will affect all aspects of their onward journey, especially their physical and mental health.

For any child being able to understand the emotions they have means they can feel less overwhelmed by them. Anyone who has seen a pre or early verbal child get frustrated because they can’t make you understand they wanted the purple cup and not the green one you have given them, will know what I mean! They may become distressed but not have the words to describe their inner state and how much the purple cup means to them and this can escalate in to an emotional overload of frustration, or they will learn to give up and switch off from trying to communicate their distress, which is never a good thing.

For those living and working with children who have, or may have, lived with domestic violence, How are you feeling today Baby Bear?, has been created to begin this vital work of enabling the children to find a voice. It can also be used sensitively in situations where an assessment of a child’s view of how they felt at home needs to be known and considered to for their future or immediate well-being and safety, such as a safeguarding or court based assessment.

Gentle suggestion and exploration done patiently and sensitively can begin the process of filling a child’s ‘feelings machine’.  Imagine a Las Vegas style slot machine as being the child, adults keep pulling the handle down to get a ‘pay out’ of feelings. “Tell me how you feel about hitting your brother/being in trouble at school/being in time out again?” “How do you think I feel about hearing you hurt someone again/didn’t do as you were asked again/finding your torn up book?” The handle is pulled repeatedly but as no one has put any dollars in the machine there are none to pay out. However, each time we explore and name a feeling with even a tiny baby, “oh I think you might be sad/worried/cross/excited”, we put a dollar in the slot machine then eventually there can be a ‘pay out!’

In homes where adults are involved in domestic violence, one carrying it out and the other trying to avoid it and protect themselves and their children from it, there is no time to have every day feelings based conversations. Once the family is safely out of it the feelings work needs to begin gently and in small ways as soon as is possible. Young children’s brains are developing and wiring up very rapidly based on what they experience and are exposed too. Connecting words to the signals their body is giving them is vital to enabling them to sort through and regulate feelings which are too big for them to live with in a healthy way.How Are You Feeling Today baby Bear? cover

How are you feeling today Baby Bear? is designed to be a tool to begin this important work with young children to enable their early year’s mental and emotional development to give them a better emotionally informed foundation for life. It is a gentle book which gives permission, insight and those all-important words to children who need to begin to process their memories of feeling frightened and confused so they can get on with being children.

You can find out more about Jane’s work, upcoming events and read more of her blog posts on her website: http://www.parentingposttrauma.co.uk/

 

You can also follow her on twitter: @janeparenting

The Inspiration behind ‘How Are You Feeling Today Baby Bear?’

Trauma Parenting Specialist and author of  How Are You Feeling Today Baby Bear? Jane Evans explains the inspiration behind the book.

Why I wrote How Are You Feeling Today Baby Bear?

From the time I was a little girl I have loved children’s books and, for the past 22 years since becoming a parent, step-parent and grandparent I have totally loved children! My professional life has been an extension of this love for them.

My work has regularly brought me into the lives of families living through the most difficult of times. For many this has been domestic abuse and violence, mental illness, addiction, homelessness, poverty and child abuse. It has always been a privilege to sit alongside them and to learn from them. My life has been full of ups and downs, my battles with mental illness and beyond domestic abuse and through it all, in one way or another; it has always been children who have been the light at the end of the various dark tunnels.

How Are You Feeling Today baby Bear? cover

For many, many years I have had a burning desire to write a book for children which would be of real use to them. In my work with children I have used story books to give them chances to explore, in a gentle way, how they might feel about complex issues they have no words for.  When I worked as a Parenting Worker with families affected by domestic abuse and violence, their parents and carers kept asking me for a suitable book to share with their youngest children who had seen and heard  arguing, fighting and other abuse.

Sadly, I have repeatedly been struck by how much the children I have worked with have struggled to find the words to describe their feelings. For most of them it has been like learning another language and has been a slow process of trying to make up for a vital missing part of their developmental journey. Similarly their parents have often shown and told me how they too have found this difficult both for themselves and with their children.

Never was this more evident than when I was working alongside families’ post domestic violence and abuse, especially those with very young children. “Is there a book I can read with them?”, parents and carers would ask me; I struggled to find the right one which would give a child opportunities to learn about the words for their feelings without being scared, or without being ‘told’ how they  might feel.

All illustrations by Laurence Jackson

All illustrations by Laurence Jackson

Finally the time came to put the words and images I had created in my mind, from thinking about how a very young child feels during and in the aftermath of domestic violence, down on paper! Baby Bear was ‘born’ with two Big Bears who are having a difficult relationship, which often erupts into arguing and fighting, all of which is heard and felt by Baby Bear.

My hope is that How are you feeling today Baby Bear? will help families and young children post domestic violence and abuse to put feelings into words, rather than feeling their only option  is to express these difficult emotions via their behaviour.  Happier, healthier children with a closer connection to caring adults will offer them the onward journey they so deserve.

You can find out more about Jane’s work, upcoming events and read more of her blog posts on her website: http://www.parentingposttrauma.co.uk/

You can also follow her on twitter: @janeparenting

Teaser Tuesday-Free Downloadable Girl Bullying Prevention Worksheets for your Tween or Teen

October is National Bullying Prevention Month! In recognition, JKP is offering two free sample worksheets for our Teaser Tuesday giveaway of activities designed to address bullying among girls.

Surviving Girlhood by Nikki Giant and Rachel Beddoe is a unique resource for preventing girl bullying by addressing the root causes and helping girls to be strong, positive individuals. The book teaches young people how to deal with bullying, offering tools, strategies and, most importantly, awareness. The five key themes to Surviving Girlhood start from the ‘inside-out’, reflecting a philosophy of understanding and connecting with ourselves, to better understand and connect with others. The five key themes are:

  • Theme 1: Being Me
  • Theme 2: Influences
  • Theme 3: Respect, Responsibilities, Relationships
  • Theme 4: Managing Relationships
  • Theme 5: Conflict Resolution

The included downloadable worksheet uses a simple activity to represent Maslow’s Hierarchy of Needs and introduce the idea of having many different types of needs, starting with essential needs.

Download ‘Maslow’s Hierarchy of Needs’ worksheet here.

Girls as young as age five are experiencing acts of bullying, disguised as friendship, that shake the carefully laid foundations of their self-image, personal values, and beliefs about peer relationships. Friendship and Other Weapons by Signe Whitson is a photocopiable resource book that provides educators, social workers and counselors with a complete, ready-to-use group curriculum to help young girls build constructive and fulfilling friendships. Based on thought-provoking discussions, engaging games, strength-discovering exercises, and confidence-boosting fun, the hands-on activities in Friendship and Other Weapons build critical knowledge and friendship survival skills such as:

  • Recognizing the Red Flags of Girl Bullying
  • Responding Assertively to Bullying Behavior
  • Realizing Personal Strengths
  • Becoming an Ally to Others Facing Bullying
  • Resolving Conflicts Directly
  • Using Technology and Social Media Ethically

The included downloadable worksheet, Silent Whispers: Two Rules for Stopping Gossip, uses a fun activity to illustrate the negative effects of gossip and rumors on constructing healthy peer relationships.

Download ‘Silent Whispers: Two Rules for Stopping Gossip’ worksheet here.

C’mon everybody – get writing!

Vanessa Rogers is the author of Working with Young Women, Working with Young Men, Let’s Talk Relationships, 101 Things to Do on the Street amongst others. In this article she gives her writing tips for aspiring authors. And, if you’re feeling inspired feel free to send in your proposals to post@jkp.com


They say that there is a book in all of us, and judging from the number of emails and Tweets I get from people in the youth work and social education field inspired to write their own, it would certainly seem to be true. So this is a collective response to those of you who have asked me for ideas of how to start writing, and to share my personal experiences of writing a book. I hope it is useful – but please remember this is only my way, which I made up as I stumbled along the way.

When I start a new resource book it is because the subject holds a compelling fascination for me. For example, Working with Young Women (Jessica Kingsley Publishers ISBN 9781849050951) came out of lots of girls’ groups that I was facilitating at the time. The young women came to the group because they had been identified as at risk of offending and aggressive behaviour, but the more I got to know them the more I thought that a lot of their behaviour was actually a response to the bad relationships they had with their peers, parents and boy/girlfriends. It seemed to me that their anger and aggression was a coping mechanism that until now had worked for them. So, this made me question how young women can build a sense of self, gain confidence and assertiveness, look at the role models they have and their aspirations for life – in a way that is interesting, non-judgemental and fun. After all, through the group work I was basically asking them to change their existing coping behaviour, (which whilst not necessarily socially acceptable to all, gave them the kudos and ‘respect’ they sought), to take a chance of being vulnerable and exploring things that hurt to find a better way with me. But it seemed that this was the foundation for everything else – e.g. if you value yourself and your body you are more likely to respect it and look after it.

So from here, as for every other book I have written, I devised a series of questions that I wanted to answer. These help me keep focused and distill the essence of what I am trying to do.

After that, I spend about 3 months researching the topic. I do this by reading around the subject and trawling the Internet for ethical and correct data and statistics, but also by speaking with other practitioners and as many young people, or in the example above as many young women, as I can, to ask my questions and test out some of my theories. By now I usually have at least one box file filled with clippings and stuff, as well as my trusty notebook (I always have at least one hardback notebook on the go) filled with points to remember and ideas for games, quizzes or activities.

One thing; all of my session plans have to be tried out with young people before I will include them. For me, this part is one of the rules of my work to keep it ethical and grounded – it has to have been tried and tested and I have to know that young people will learn from it and more importantly enjoy doing so.

As I write constantly this means that I often have ideas stashed on my computer that are developed later when the opportunity presents itself. I try my best to include lots of learning styles in the activities and this might mean that I write the same learning outcomes three times, with three different ideas for delivering them. So, as I try them out with young people I use the one that goes best and dump the rest. I also ask young people to give me feedback as the book comes together, which I value as they don’t hold back if they think it won’t work!

Once this is done, I stick my main points on bits of paper around my desk and tell everyone that I am going to be ‘writing’. To my family this means that I am likely to be distracted, a bit bad tempered and the dinners will be rubbish for a while – but the good news is that I will be in the house for days on end and easily tempted to buy take-aways!! To my friends it means that if I do see them I am probably going to bore them witless by obsessing over my blossoming (or not) book. All training and other work is put on hold. And then – I write it.

I tend to write ‘all over’ my books – meaning that I might write part of the intro, then get a bit stuck so move on to one of the later chapters.  It may look chaotic but it isn’t – more like putting a jigsaw together, because by this stage I know exactly what I want to write and how it will look at the end. I tend to really get into this bit so write day and night, with no adherence to office hours – I actually prefer working through the night so it is pretty usual for me to be writing between 2 and 5 a.m.

Once it is done – which usually takes about 7 days end to end – I put it away for at least 3 days before getting it out and editing / doing the final writing.

Then it is off to Jessica Kingsley Publishers …… and I miss it like mad …… get a bit sad, like at the end of any relationship …… do any edits or re-writes asked of me by the editors and proof readers ….. and leave the printers to get on with it. In my head it is over.

I try and build a break in at this point so that I can have fun with friends and family and shake off the topic that has been all consuming for what might have been up to a year. And then, just when I think that I have had enough of writing, something sparks my interest – and the whole cycle begins again.

I hope this helps – but as I say all writers are different and I am sure you will find your own way of working. My only advice would be, write for you and choose a subject you feel passionate about – if you aren’t at the start, you definitely won’t be at the end! My very best wishes and good luck with it – let me know how you get on.

 

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:

[youtube]http://www.youtube.com/watch?v=XGh8PXIxRkY&feature=youtu.be[/youtube]

 

© 2013 JKP blog. All Rights Reserved.

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

 

Podcast: Dramatic Problem Solving with Steven T. Hawkins

Steven Hawkins, author of new book Dramatic Problem Solving: Drama-Based Group Exercises for Conflict Transformation, speaks to This is Wisdom – Radio about his background in theatre and how he came to develop his creative approaches to problem solving within education. He talks about how the Dramatic Problem Solving approach has brought personal and community change to some of the poorest people in Costa Rica as well as corporate board rooms.

You can listen to the podcast here, or go to This is Wisdom – Radio for more details. You can also find out more about Steven’s work on his blog: http://www.dramaticproblemsolving.blogspot.co.uk/

 

In Search of Youth Work by JKP author Vanessa Rogers

An interesting and thought provoking article from JKP author, Vanessa Rogers on what it is to be a youth worker today. Vanessa is the author of a number of titles on working with young people including, Working with Young Women, Working with Young Men, Let’s Talk Relationships, 101 Things to Do on the Street, and new from JKP the Little Books on Alcohol, Drugs and Tobacco Set.


What is Youth Work?

Today I realised that I have been a youth worker for over 15 years, yet I still struggle to explain exactly what that means, especially to someone outside of the profession. It is not a simple answer and I have even been known to say, ‘social worker’ in certain social settings just because it is easier.

The irony is not lost on me; that I am prepared to betray my profession, even though I feel so passionately about it, because I can’t be bothered to explain what I do and that it involves more than playing pool and sorting out squabbles about which track to play next on the iPod in the youth club. Explaining detached youth work is even harder, and has even been met with snorts of laughter at the thought of being paid to wander the streets talking to unknown young people. ‘But what is the point?’ is a constant refrain.

It has not always been so. There was a time not that long ago when it would be hard for me not to weigh in with my views. In fact, many of my ex-students could stand testament to the fact that, ‘what is youth work?’ is one of my favourite assignment titles, and the 500 words produced in response are a constant source of interest and heated debate.

Then it dawned on me that perhaps the sinking heart I get whenever someone asks me what I do for a living is not merely personal apathy, but because I have had the conversation one too many times. The sense of justifying what youth work is, why it matters and the unique place it has in supporting young people – not only amongst friends, family and strangers but also with youth workers and other professionals – has become habitual. I realised that I am a bit tired of the struggle and don’t want to spend time any more time analysing the process at a cost of actually doing it less.

It hasn’t always been so difficult, although I am in no way harping back to some mythical golden age of youth work. I am simply pointing out that if you had asked me 15 years ago what I did my answer would have been pretty easy – an area youth worker for the Youth & Community Service responsible for developing girls work, work with young parents and managing a large and busy youth wing on the site of a school in an area described as ‘deprived’. So far, so clear.

The role of a Youth Worker

Fast forward and my role, but not my professional title, has changed so many times that writing a CV can be a daunting thing. Terminology for the young people, or ‘client group’, has changed from young people ‘at risk’ through ‘vulnerable’ to ‘targeted’; youth services have dropped the ‘ & community’ tag and been variously part of the education, leisure, Connexions and social care departments.

Responsibilities have changed to include meeting parents, undertaking social care assessments, creating community profiles and measuring work by the number of accredited outcomes achieved.
What constitutes ‘youth work’ has changed so many times that it can now be tagged on to virtually any service that works with young people.

But is this a good or bad thing? Is the increase in those using traditional youth work skills to engage with young people something to be celebrated or lamented? All I know is that ‘youth work’ is a notoriously difficult term to describe, and it isn’t getting any easier. The task of trying to find a pithy one-liner to sum up the collective aims of so many different clubs, societies and detached projects is almost impossible.

Perhaps it is that so many people now describe themselves as ‘youth workers’, whilst working in areas more traditionally associated with social workers or youth justice? I have even spoken with police officers that say they do ‘youth work’. Really? Are the professional boundaries so completely enmeshed? Please note this isn’t about professional qualifications, or even the lack of them, more a questioning of how the ethos of voluntary participation and the gradual process of building positive relationships and engaging and empowering young people fits within a law and order or social care framework.

The ethos at the heart of Youth Work

Historically, youth work did not develop just to ‘keep people off the streets’ or to provide aimless amusement, it has always offered social and political education in an informal environment. Good youth work may look as if it just ‘happens’ but the success of it actually depends on good planning, clear aims and measurable outcomes. This ethos should be at the heart of all youth work – especially detached projects. Surely an exciting detached project that motivates young people to get involved should result in more, not less, youths on the street? And that should constitute success?

Put simply, providing young people with a ‘good time’ is not enough. Effective youth work should offer young people the opportunity to meet, socialise, develop new skills, explore the world around them and learn to question and challenge what they see effectively. Detached projects should not be about forcing young people off the streets and away from adult eyes, but more about building trust and developing interesting projects that are relevant to their needs, reflecting the things of importance to them. Which is unlikely to be the same as the media focus on demonizing young people as part of a lawless counter-culture.

As I see it the need to build two-way respect between young people and other members of their community is paramount – after all it is hard to encourage young people to take up their responsibilities and become active citizens if they are treated like social outcasts. Why would you want to be part of something that clearly doesn’t want you?

Perhaps the answer is purely financial. In the struggle to chase funding and secure projects we have been forced to chase the pound, rather than offer what young people truly want. Or maybe as numbers dwindle in traditional old-style youth clubs what’s on offer is simply outdated and no longer meets the needs of teenagers. In that case let’s stop hanging on to the solutions of the past and try new ideas.

Listening to Young People

Young people can be innovative and visionary, with energy and enthusiasm to shape and change the world. To do this they need to find ways to get their voices heard and be able to see that their participation in things like youth councils, forums and consultations actually makes a difference. To be honest, as an adult I am happy to give my opinion on things that matter to me but I get disheartened and then disinterested if nothing ever comes of it and I don’t receive any feedback. Too often I think young people are let down because although they are told that their opinions count, when it comes to money and budgets, they don’t. Participation has to be more than a paper exercise or a way to ‘tick boxes’.

Reclaiming Youth Work

So I think it is time for youth workers to stand up and reclaim youth work by celebrating how different it is to other work with young people. It should be seen as a whole, not as a useful pick’n’mix to compliment other services, and defined in our own terms – whether that is through a Youth Work Academy or some other collective process – before someone else does it for us.

In another 15 years time I don’t want to still be ducking the question, ‘what do you do for a living?’ – I want to be able to say (still with pride), ‘I am a youth worker’, and for that to mean something.

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.