Counselling, Supervision, Training, Research, Teaching, Writing. Providing therapeutic services to the people of East Lancashire and beyond.

Friday, 30 March 2012

Forced Marriage

The issue of forced marriage has been on my radar since I started supervising a dissertation on the topic at Blackburn College. The dissertation, which includes primary research with service providers and victims, questions the wisdom of creating a separate offence of forced marriage. This week the consultation on whether to introduce a law criminalising forced marriage ended and we now await the government's decision. You can read about this in the following BBC News report

In one respect the decision to criminalise forced marriage would be an excellent move. It would send out the message that our society does not tolerate this particularly nasty form of domestic violence, often accompanied by the worst kinds of physical, sexual and emotional abuse. Surely it must be right to protect vulnerable and isolated young women and men with the full force of the criminal law?

Those who object to a new law suggest that the move criminalises those parents who have forced their children to marry and potentially makes members of the extended family accessories to a crime. This puts children and young people subject to a forced marriage in the most terrible dilemma, facing the possibility of testifying against their parents in court. So it could be argued that a separate crime could make it even more difficult to protect individuals from harm by pushing forced marriage further under-ground It could also be argued that there are sufficient measures available to protect young people from this kind of domestic abuse, including, for example, Forced Marriage Orders, available under the Forced Marriage (Civil Protection) Act, 2007. There are laws covering domestic violence and harassment that could be used.

If we do not pass legislation are we are at risk of failing to protect individual human rights? And isn't choice about if we marry and whom we marry a basic human right? Article Sixteen of the Universal Declaration of Human Rights states categorically: "Marriage shall be entered into only with the free and full consent of the intending spouses". The criminal law protects children and young people who are being sexually or physically abused. Surely It ought to protect those who are being abused through forced marriage too? Of course whether the victim reports the crime is a matter for them, but I think they ought to have that course of action open to them.

The Forced Marriage Unit (FMU) is a joint-initiative with the Home Office. In 2011 there were 1468 instances where the FMU gave advice or support related to a possible forced marriage. There were 66 instances involving those with disabilities (56 with learning disabilities, 8 with physical disabilities and 2 with both), and 10 instances involving victims who identified themselves as LGBT. Of the 1468 instances, 78 per cent were female and 22 per cent male.

For more information about forced marriage please see the website of the Foreign and Commonwealth Office Forced Marriage Unit or read the Survivors Handbook Thank you to Zahida for making me aware of this issue.

Saturday, 24 March 2012

Mental Health and the Military

Events in Afghanistan and numerous articles on post-traumatic stress disorder have caused me to visit the web site of the King's Centre for Military Health Research and read once more the Centre for Mental Health Report, Across the Wire: Veterans, Mental Health and Vulnerability (25 October 2010). Written by Matt Fossey, the report gives an over-view of the mental health of British military personnel and the support they receive under the military covenant.

The impression I get from watching the media is of large numbers of soldiers suffering the effects of post-traumatic stress as a result of the horrors of war. Fossey's report suggests this is not the case, with just one per cent of service personal each year discharged because of psychiatric problems. According to Fossey, only 20-25 individuals per year are discharged because they're suffering from Post-traumatic Stress Disorder (PTSD). I don't think these figures give a complete picture of the mental health of service personnel leaving the military. How many military personnel choosing to leave the forces are struggling with the effects of acute and chronic stress? How many of those disclose the fact? How many leave self-medicating with alcohol? Maybe the Ministry of Defence and personnel leaving the forces have a common interest in not acknowledging the role that chronic and acute stress might play in an individual's decision to leave the armed forces. I'm told by colleagues working with ex-military personnel that many do not get their PTSD diagnoses until many years after leaving the forces and that not many of those were discharged on health grounds.

In fact the Fossy Report does highlight a much deeper problem when it considers two surveys about the health of ex-service personnel. According to one survey of 9,990 UK veterans four per cent were living with PTSD - four times the rate for the general population. Another survey of 3000 veterans suggested a rate of 19%. These surveys also point to high rates for alcohol misuse and general mental health problems. Fossey argues that the mental health of ex-service personnel isn't bad when compared with the mental health of the general population. Throughout the report Fossey seems to play down concerns about the mental health of UK veterans, yet if the rate of PTSD amongst the general population was 19% (it's 10% in Israel) it would be a catastrophe.

Fossey refers to the history of PTSD and it's numerous manifestations (Railway Spine, Shell Shock and Battle Fatigue). It seems to me that the military are still reluctant to accept combat stress as a cause of mental disorder. Blaming the individual for 'buckling under pressure' certainly happened during the Second World War as Fossey points out:

During WWII, the unfortunate acronym ‘LMF’ (lack of moral fibre) was stamped on the medical cards of aircrew who, through reasons of extreme stress or trauma, were unable to perform their duties – a millstone for many in future civilian lives (Jones, 2006). The acronym LMF was only removed from usage in 1960 by RAF Psychiatry

Having read the excellent Trauma by Gordon Turnbull I'm sure that military psychiatry has advanced since the 1960s but Fossey reminds us of the role "personality factors" still play in explaining (and excusing) high rates of post-traumatic stress amongst the military:

While there can be no doubt that those suffering from complex PTSD have many needs, some authorities debate the nomenclature and suggest that personality factors (which have been mostly a result of pre-service experience) are more important determinants of health in such people than their military experiences.

It impossible to say whether or not these individuals would have developed PTSD had they not joined the military, but I'm pretty sure joining up increased the risk.

Fossey argues that there's one group amongst the military who do raise concerns. These are young men under twenty-four years of age with less than four years service. They leave because military life doesn't suit them, and because they have served for a short time they get less help with their resettlement than personnel with long service. This group of young people are 2-3 times more likely to commit suicide than the same age groups in the general and serving populations. Fossey's Report suggests we should direct more resources at those young people who leave the forces early rather than those who serve for a long time and experience numerous tours of duty.

Fossey is arguing in his report that the military tends to recruit low educational achievers from poor areas. Many of these men and women have pre-existing problems before they join. They are recruited and successfully changed by the military and have long and successful careers. A number, however, are unable to settle and are discharged. Their inability to serve is not due to their experience with the Forces but the pre-existing problems these young men already have with authority, alcohol, drugs and crime. A brief survey of the cases I am familiar with does indeed suggest long-standing problems that pre-date their military experience.

So, what can be said about the mental health of British military and ex-military personnel. Firstly, most individuals serve in the armed forces without suffering any serious mental health problems at all. Secondly, there is a significant minority who suffer alcohol addiction, supported to some extent by the military's drinking culture. Thirdly, there is another group, young men at risk of depression and suicide, if they leave the forces early and without an adequate resettlement plan. Fourthly, a minority of personnel - between 4 - 19% - are suffering from the symptoms of PTSD as a result of combat. It is these three groups that require resources, care and support.

Sunday, 18 March 2012

Trauma in Afghanistan

Staff Sergeant Robert Bales is accused of shooting to death sixteen Afghani civilians, including nine children, last week. Yesterday the New York Times discussed whether the strain of multiple tours and the stress of combat might have caused Sgt Bales to behave as he did. A US army spokesman, Colonel Thomas W. Collins, dismissed the suggestion, arguing that, "Lots of soldiers have four deployments, and they’re not accused of things like this". According to the New York Times the profile of Sgt Bales - a 38-year-old father of two - is typical of many soldiers and marines serving in Afghanistan; like many combat soldiers, Sgt Bales had experienced psychological trauma during his service: the day before the massacre he witnessed a colleague lose a leg in an explosion. Reports suggest that Sgt Bales was drinking alcohol before he left the US military base in Kandahar on the night of the massacre; but Mr Browne, his lawyer, says there is no evidence 'on the public record' of Sgt Bales having a drink problem. Mr Browne does suggest, however, that Sgt Bales was suffering from Post Traumatic Stress Disorder (PTSD) having himself lost part of a foot in a mine explosion. The evidence suggests, therefore, that against a background of chronic and acute stress, Sgt Bales experienced a severe mental breakdown, marked by a murderous rage that was targetted at innocent villagers.

Monday, 12 March 2012

Book Review: First Steps in Clinical Supervision

Cassedy, P. (2010) First Steps in Clinical Supervision: a Guide for Healthcare Professionals, Open University Press.

Cassedy has written a useful introduction to clinical supervision for those new to the profession; and I say profession because I'm a strong believer in the notion, put forward, I think, by Hawkins and Shohet, that supervision is a discrete set of skills which properly applied can benefit anybody working in the helping professions. Hence I work with counsellors, but I've also worked with teachers, group facilitators and domestic violence workers.

I'm sure Cassedy would agree with the view that supervision has the ability to build the capacity of skilled helpers in all their many forms. His book is specifically aimed at health care professionals who have been given responsibility for clinical supervision or for health care professionals embarking on supervision training.

The book begins with an introductory chapter, which, like all its friends, begins with a list of learning outcomes, describing what the reader will be able do after reading the chapter. The introductory chapter gives an overview of clinical supervision as a discipline and provides a place to address diverse topics such as the benefits of supervision and the reasons for becoming a supervisor.

Chapter two addresses the first supervision session and chapter three describes the qualities of a healthy supervision relationship. These chapters, like others in the book - on the three functions of supervision and active listening skills - are basic fayre and pretty descriptive, appropriate for practitioners completely new to supervision.

The book has a couple of interesting chapters, even for experienced supervisors. Chapter six applies Heron's Six-Category Intervention Analysis to supervision work. This provides a model for examining the interventions used by a supervisor and a framework for identifying 'degenerative' interventions. Heron's model works so well when applied to supervision that Cassedy's chapter had me returning to Heron's original work.

Cassedy also has a chapter demonstrating how Gerard Egan's Skilled Helper model can be used in supervision. Again, this fits well with the aims of supervision, but turns supervision into a problem solving and cognitive process at the expense, perhaps, of emotional and unconscious material. We can see here differences between clinical supervision and counselling and psychotherapy supervision. From conversations with NHS therapists, clinical supervision in the health service seems to have a strong normative function. The final three chapters of the book are about reflective practice, evaluating supervision and avoiding stress and burnout. So the book covers a lot of ground, breadth rather than depth, and for someone new to supervision it is a good enough starting point.

Brief Thoughts on Developmental Trauma

An interest of mine at the moment is the idea of 'developmental trauma'. Practitioners and researchers are attempting to include developmental trauma in the latest version of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association. I recently read a brilliant article about this by Mary Sykes Wylie which appeared in the Psychotherapy Networker as "The Long Shadow of Trauma". Wylie writes about the impact of early trauma on later life; but she also writes a fascinating piece about the importance of research in changing the minds of the medical establishment.

Developmental Trauma is the phrase used to describe a cluster of symptoms that result from early experiences of trauma, and in particular abuse and neglect. These experiences leave their mark on brain development (see, for example, this article in Science Daily or this one in New Scientist) and on the child's psychological, emotional, social and moral development. Indeed a child's ability to regulate their emotions and manage their behaviour will be impaired, leaving them vulnerable to alcohol and drug misuse, risk taking, violence, attachment problems and long-term health problems. In my current work as a counsellor I see the signs of developmental trauma; but it was as a probation worker and a youth justice worker, that I saw most clearly the negative impact of early neglect and abuse on the lives of individuals.


Adverse Childhood Experiences Study referred to in the The Long Shadow of Trauma article, this mammoth study is demonstrating the long-term impact of early trauma.

Bessel Van der Kolk's Trauma Centre , website of one of the world's leading experts on post-traumatic stress and including numerous links to other resources

The Social Work Policy Institute has some good research pages on childhood trauma and recovery

National Child Trauma Stress Network, an excellent source of information and statistics about the impact of early abuse and neglect

Saturday, 3 March 2012

Theatre Review: Saturday Night and Sunday Morning

I went to see Saturday Night and Sunday Morning at the Royal Exchange Theatre in Manchester tonight. It reminded me of the first play I ever saw at the Royal Exchange: Jim Cartright's Road, which I must have seen fifteen or twenty years ago. Cartright's play was a joy to watch, a raunchy, foul-mouthed and hilarious tribute to working class life in Lancashire during the Thatcher years. The play was held together by Scullery the narrator, played by the excellent Bernard Wrigley, who roamed the set and introduced the different scenes. Genius!

Saturday Night and Sunday Morning does not have the riotous humour of Road. Adapted from Sillitoes fine novel it moves at a slower pace. It depicts working class life in Nottingham in the 1950s, it's about the monotony of factory work in mundane post-war Britain versus the hedonism of Arthur Seaton the play's protagonist. Seaton works in a bicycle factory on 'good money' or £14 per week. He spends his money on clothes, beer and women: short-term gratification, because according to Seaton, "The longer you keep your money, the less it's worth". A word here about the excellent performance of a young actor called Perry Fitzpatrick, who plays the confident, amoral, hedonistic Arthur Seaton. Fitzpatrick is on stage throughout the play, his costume changes are completed on stage and mark the changing scenes as well as his changing social roles.

Fitzpatrick plays Seaton with a swagger but captures too the subtle changes in Seaton's values and beliefs as he drifts away from his old life of hard drinking, sex with married women and fights with their husbands to commitment, monogamy and maturity - love, as they say, conquers all. There are subtle changes too in Seaton's political views; so there are a couple of monologues in which he attacks the government, the Labour Exchange and the tax man for exploiting him and robbing him of his hard earned income. But whilst the young Seaton voted communist with his father's polling card, the older Seaton appears much more sceptical of social organisation and much more individualistic.

The responsibility for carrying the play is with the egotistic Seaton, and fittingly the cast and even the furniture moves around him; but credit must be given to the rest of the cast, especially Clare Calbraith (Brenda) for stepping naked into a hot bath - a scalding bath and a pint of gin brings on the miscarriage she seeks after Arthur Seaton gets her pregnant. The cast work hard to keep the show lively and entertaining as it faithfully lays before us the contents of Sillitoe's novel and the growing pains of Arthur Seaton.