Depression and suicide

7. Depression as an indicator of suicidal thoughts and actions. One sees a great deal written about suicide and depression in the literature and unfortunately it is quite a misunderstood area. All sorts of statistics quoted. For instance George (2008) states, "A retrospective study of 132 young people who completed suicide in Western Australia found that nearly three quarters had shown definite signs of depression in the weeks prior to their death"(p.25) Or, "Depression increases the risk of suicide by 15 to 20 times, and about 4% of people with depression die by suicide."(p1373), Hawton, and van Heeringen, (2009). This of course means that based on this research ninety six percent of people with depression do not die by suicide. Other research has varying figures. Clark and Fawcett (1992) estimate that fifteen percent of those with a diagnosis of major depression will complete a suicide. The statistics tend to waver around the ten percent mark which means that the vast majority of those with depression will not complete a suicide attempt. There are many depressed people who are not suicidal at all. Of course this does not mean that one forgets about making an assessment of suicide with the person reporting depression but one needs to be realistic about its occurrence which is not often found stated in the literature.

Key symptoms of depression related to a risk assessment

In real terms depression is merely a collection of symptoms, it is not so much that depression is linked to suicide it just happens that people who are suicidal have symptoms which are not uncommon in depressed people as well. In using this measure in a suicide risk assessment one does not enquire about depression per se but one enquires about some of the symptoms found in the depression that the person is displaying.

The DSM-IV provides a list of symptoms which define depression, these being:

1. Depressed mood most of the day which can include a sense of hopelessness.

2. Loss of interest or pleasure (in all or most activities, most of the day).

3. Large increases or decreases in appetite (significant weight loss or gain).

4. Insomnia or excessive sleeping (hypersomnia).

5. Restlessness as evident by hand wringing and similar other activities (psychomotor

agitation) or slowness of movement (psychomotor retardation).

6. Fatigue or loss of energy.

7. Feelings of worthlessness, or excessive or inappropriate guilt.

8. Diminished ability to concentrate or indecisiveness.

9. Recurrent thoughts of death or suicide.

Taken from, American Psychiatric Association (1994).

In this diagnostic system one needs to have five or more of these symptoms to be diagnosed as depressed. Thus every suicidal person automatically has one symptom of depression already as shown in symptom number nine. The best clinical predictors of suicide in depressed people include previous self-harm, hopelessness and suicidal tendencies. (Beck, Steer, Kovacs and Garrison (1985) and Beck, Brown and Steer (1989) both found hopelessness to be one of the best indicators of suicide risk). If the depressed person reports a loss of appetite, psychomotor agitation, excessive guilt, hypersomnia and increased indecisiveness then they meet the criteria of depression but show none of the best clinical indicators just described. Indeed unless the depressed individual reports the last symptom, recurrent thoughts of death and suicide, it seems safe to say that the person is not a suicide risk at this time. They are not even thinking about suicide at this point even if they have all eight other symptoms of depression. If a person presents as depressed one firstly asks if they have the symptom of thoughts of suicide and if they do then one also enquires about a sense of hopelessness and any previous self harm. If they present with all three one is getting a much more accurate assessment of the current level of risk.

In the literature one finds very little research on the number of people who report depression and who report no recurrent suicidal thoughts. One has to search long and hard and three such research studies were found. The first from many years ago by the 'father' of depression, Arraon Beck (1967). He presented research results which examined the presence of suicidal wishes in the depressed person. He makes the distinction between neurotic depression or the milder forms of depression and psychotic depression or the more severe forms of depression. (This distinction will be discussed more later in this chapter). The results were:

Mild or moderate level of suicidal wishes present:

Neurotic depression - 58%

Psychotic depression - 76%

Severe level of suicidal wishes present:

Neurotic depression - 14%

Psychotic depression - 40%

More contemporary research by Akechi, Okamura, Kugaya, Nakano, et al (2000) reports that in patients with major depression fifty three percent had suicidal ideation. Wada, Murao, Hikasa, Ota, et al. (1998) also report a similar finding of around fifty percent of those with major depression having suicidal urges as well. This allows the conclusion that about fifty percent of those with some form of depression do not report any recurrent suicidal thoughts. Thus it seems safe to say that fifty percent of depressed people are not at risk of suicide as they are not even thinking about suicide let alone planning anything.

Timing of the depressive episodes

If the individual does present as depressed and does show the principle signs of recurrent suicidal thoughts, a sense of hopelessness and previous self harm then of course this is an important factor in the risk assessment and definitely requires more investigation. One of the more important aspects to investigate is the course and stage of the depression. As stated by the Bayley (2004) depressive episodes can be single, recurrent or chronic and this has significant implications for the assessment and management of the suicidal individual.

For about five to ten percent of depression sufferers the depression is chronic. If an individual with chronic depression also has recurrent thoughts of suicide then the level of risk increases and over time it could be seen as continuing to increase. In the longer term this person could be seen as quite a significant suicide risk. One would to be questioning the individual as to their feelings about tiring of life and particularly a sense of hopelessness. These individuals have a poor quality of life with the spirit crushing depression and often quite unpleasant side effects from the medication like obesity, lack of energy and so forth. If they have tried just about every type of medical and psychological treatment with little improvement one would be assessing a definite increase in the risk of suicide.

To make matters worse there is not much one can do in their management. A no suicide contract is of less use as there is no end in sight for the depression. As the suicide risk increases over time one can place them in hospital or on some kind of suicide watch but what does that achieve? It simply relocates them geographically and how long does one keep such a person in hospital as they will be depressed upon release.

However for most depression is cyclical as is shown in diagram 4 with the mood changing over time from a normal level to a depressed level and back.

Diagram 4

The cycles of depression

As stated in the Bayley (2004) the rate of recurrence of depressive episodes is quite high, "50% of people who have had one episode of depression will relapse, 70% of people who have had 2 episodes will relapse, and 90% of people who have had 3 episodes will relapse"(p159). The average duration of an untreated episode is about twenty to twenty six weeks but many can have much briefer episodes of around four to six weeks. If treatment is obtained early then the duration and severity of the episode may be significantly reduced.

Types of depression

In using depression as a measure to assess suicide risk one needs to distinguish a number of different types of depression. As is shown in diagram 4 one can move from a normal mood range into the range of dsythymia. In this phase the depressive symptoms are at a moderate degree. Historically this has also been known as neurotic depression and I use the terms interchangeably. This is seen as less severe than the next level which is called a major depression. In this phase the depression symptoms are at a severe degree. Sometimes this is called 'clinical depression' and the individual is significantly incapacitated and is very depressed. Also at this level one can have a condition known as psychotic depression. This is where the individual has the symptoms of major depression plus some psychotic symptoms. This terminology has been around for many years and psychotic depression is well summarized by Beck (1967) who says it is "...characterized as including patients who are severely depressed and who give evidence of gross misinterpretation of reality, including at times delusions and hallucinations"(p82).

In summary in this model we have:

Normal mood

Dysthymia or neurotic depression

Major depression and psychotic depression

In diagram 4 we have an individual who begins with a period of normal mood who then moves into a phase of depression that is consistent with the diagnosis of dysthymia. Eventually that depressive episode ends and he recovers again for a period of normal mood. Unfortunately at a later time he again moves into a more severe episode of a major depression which he eventually recovers from and moves back to a state of normal mood. To assist with making a suicide risk assessment one can create a graph like this for the person who complains of depressive episodes.

In assessing the depressed person one need to look at four aspects of the depressive cycle W, X, Y and Z. Firstly one is wanting to assess the length of the non depressed periods (W) and the lengths of the depressive episodes (X). Of course this relies on the person having had previous episodes and one simply takes a history of the person in this way. How many have there been and how long were they? Also were there any precipitating factors such as marital problems or financial difficulties that lead to the depressive episode. These can then be charted on a graph as is shown in diagram 4. People tend to behave in patterns and one is obtaining this information to assist in predicting future episodes and thus future times when suicidal urges may increase in conjunction with the depression. Of course future episodes may be different to past ones but this does give some guidance to assist the suicide risk assessor.

For example if there is a pattern in the timing of the episodes one then knows when approach the person for a risk assessment in the future. A good example of this is with what has become know as Seasonal Affective Disorder or SAD. Typically the depressive episode begins in autumn or winter and remits in spring. Alternatively previous depressive episodes may be related to particular events such as examination time at college or when a loved one has to travel away for work. Plotting the 'W' and 'X' of the depressive episodes will allow the risk assessor to improve the timing of their assessments.

Degree of depression and suicidality

One also needs to assess the quality of the depressive episodes by making an assessment of the 'Y' component. Here one assesses how depressed the person becomes, how the person has felt in past episodes particularly in relation to suicidal thoughts. As mentioned before the system being presented here distinguishes between normal mood, dysthymia or neurotic depression, major depression and psychotic depression.

This is an important component to distinguish in a suicide risk assessment as there is some research which concludes that those who are more depressed are more prone to suicidal thoughts. In their research on depression and suicidal thoughts Garlow, Rosenberg, Moore, Haas, et al (2007) report “These results suggest that there is a strong relationship between severity of depressive symptoms and suicidal ideation in college students...”(paragrpah 1). In addition Perroud, Uher, Marusic, Rietschel, et al (2009) state “Increases in suicidal ideation were associated with depression severity...”(p2). Finally Beck (1967) cites research which shows that a severe level of suicidal thoughts were present in fourteen percent of those with neurotic depression and in forty percent of those with psychotic depression. In conclusion, the more depressed one is the higher the risk level of suicidal thoughts. Thus one can see the importance of making the 'Y' component assessment of the reported depressive episodes.

As just noted the person with major depression or psychotic depression is at more risk of suicidal thoughts than the person with dsythymia. However it seems reasonable to conclude that the person with psychotic depression is still at even more risk than the person with major depression as a psychotic depression involves a major depression plus the presence of psychotic symptoms. That is the person experiences severe depression as well as psychotic delusions and hallucinations and thus the features discussed above in point 4, "History of mental illness" become apparent as well. There is sort of doubling effect of suicide risk factors in this instance. For example the person with psychotic depression is likely to be more regressed than someone with major depression because the psychotic features result from very poor Adult ego state functioning and thus there is increased regression. In addition the psychotic is more prone to command hallucinations as well. As a result, of all the types of depression the psychotic depression is probably the one of highest risk value when making a suicide risk assessment.

Finally in diagram 4 one needs to make an assessment of 'Z' in the depressive cycle. Suicide risk may increase as the person improves particularly in a major depression or a psychotic depression. In these depressive states the person is so depressed that they become incapacitated. They are so depressed that they literally do not have the energy to think seriously of suicide or certainly making any definite planning moves. As the depressed state lifts, along with that comes an increase in energy which may bring about an increased ability to act on any self destructive wishes, as they improve one may need to be more vigilant as they reach that part of the depressive cycle.

In addition for the individual with psychotic depression as the depression lifts the psychotic symptoms may begin to subside as well. Their Adult ego state becomes more functional and thus planing a suicide attempt becomes more of a possibility. Most suicides occur in the non-florrid stages of a psychotic episode when the person is relatively free from acute symptoms. Of particular note in suicide risk assessment if the person is at one of the lower points in the depressive cycle such as at stage 'Z' and all of a sudden shows significant improvement, that may be ominous sign. They may have made the decision to kill self and are just getting organized and waiting for the right time.

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Engage the enemy in therapy.

I have talked before about certain treatment strategies that I do with things like panic attacks and eating disorders.

If a person presents with panic attacks I will at some point ask them to have a panic attack there in the session with me. Some look at me in disbelief, state that they came here to stop having panic attacks and refuse but most will go through with it and produce the panic to varying degrees.

Others who may be bulimic I will get them to make a homework contract to throw up at least once this week. If their purging is not a physically harmful levels that is.

In the past I have tried to explain the theory behind this and never really felt that I have explained it adequately. I have not been satisfied with my explanation. The other day I was relaxing in front of the TV, surfing the channels with my remote and I happened on an interview with Mel Brooks.

He talked about a number of things including the parody that he does of Adolf Hitler in one of his comic sketches called the Hitler Rap.

This has caused quite a controversy as some argue that making fun of Hitler trivialises what he did to the Jews in the second world war. As he explained why he did such a parody I realized he was explaining exactly why I ask the panic attack sufferer to have a panic attack. There he was saying precisely why I do what I do.

If one gets to know thy enemy and engage thy foe then it disempowers them. If one only ever addresses the topic of Hitler in very sombre and serious ways then that is making him to be more important. To engage Hitler in a funny way reduces his impact and importance was the basis of Mel Brooks’ argument.

When a client comes to therapy the first thing they do with the therapist is spend a great deal of time and energy defining the problem, discussing its causes, seeking to stop it, remove it, side step it and so forth. All this focus on the problem in one way empowers it. It makes it even more important in the person’s mind.

Hence I suggest the client at times engage the foe and produce a panic attack, or for the bulimic to go and purge. Panic attacks come and panic attacks go, nobody has ever gone crazy or died from a panic attack, throwing up is throwing up, not the end of the world. It disempowers the enemy (the symptom). It is not something of great awe and immensity.

The other point that is different from Mel’s parodies is that it also defines the therapeutic relationship. If I as the therapist also hold the problem in great awe and dread, such that it must be avoided at all costs, then the client has the therapist and the therapeutic relationship confirming the belief in the power of thy enemy. If I suggest to the client they go and do purging homework they see that I am not overawed by it.

I certainly understand that it is a painful problem for the individual and empathise with that but it does not fill me with fear and dread. This will also have a disempowering effect of the problem in the client’s mind. Hence my rule of thumb about treating eating disorders, never spend more than 50% of any session discussing food, weight, eating and so forth. Talk about other non food related matters.

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Libido and relationship problems

I did a bit of supervision the other day with a therapist who was asking about a couple she was working with.

This couple thought they had a sex problem with what the DSM calls the Hypoactive Sexual Desire Disorder. This is a significant absence of sexual desire that causes distress. This couple did it about once every couple of months which means statistically they were much less than average and they thought that is was a sign of a failing marriage. Both parties had quite low libidos.

So what is the average? For Australians it is:

18 - 24 years = 3.25 times per week

25 - 34 years = 2.55 times per week

35 - 44 years = 2.00 times per week

45+ years = 1.00 times per week

(OK! Enough with the jokes about doing it 0.25 times.)

I have always wondered how they get these statistics. Is it like a street side interview? There you are walking in a local shopping centre and you are approached by a heavily bespectacled woman, who’s hair is bound tightly back, she is in a white lab coat, carrying a clip board and she asks you how often do you do it?

And once the statistics are obtained how reliable are they? Lets face it guys may tend to exaggerate. When asked how often they do it they may huff and puff a bit, push their chest out and say they get ‘on the job’ everyday.

As we know when men get together and discuss their sexual exploits with the fairer sex they are prone to exaggeration. The general rule of thumb is take what they guy claims happened, divide it by 2 and you are probably some where near the truth. If he says he met a woman in bar last night, took her to his apartment and scored a home run that means he probably got to second base.

However the statistics don’t really mean anything when it comes to an individual couple. If they do it once every couple of months then they are very below the statistical average but what one is really looking for is how equal are their libidos. One is hoping for a relatively similar level of libido between then husband and wife. If their libidos are both low, both medium or both high then they do not have a sex problem at least in terms of desire.

If one has a low libido and one has a high libido then they have a significant relationship problem that can easily cause significant damage to their relationship.

Sex is usually a very Free Child to Free Child transaction. Sex that is good for a relationship is this even though people can have sex in other ego states. However if the desire for sexual activity is very different between husband and wife then they do have a relationship problem. If he has a high libido and she has a low libido then what happens when he requests sex.

If she says ‘yes’ when she wants to say ‘no’, then one problem is solved and another problem is created. His FC feels satisfied and her FC feels hurt. If this happens repetitively then her hurt FC will cause relationship difficulties and thus they both suffer.

If she say ‘no’ when she wants to say ‘no’ then one problem is solved and another problem is created. Her FC feels satisfied and his FC feels hurt. If this happens repetitively then his hurt FC will cause relationship difficulties and thus they both suffer.

When this happens sex can easily get entangled with power, punishment of the other party and so forth and by that time the relationship can start to get into very troubled waters.

So what is meant to happen according to the counselling textbooks? Well try before you buy may be a good idea. If a person is very sexually driven then it might be a good idea to seek a partner who is a little bit similar. Of course that is easier said then done once love gets involved.

As with so many relationship difficulties a bit of compromise on both sides can go along way. Satisfying sex does not have to involve intercourse, which is also a common solution if one party has herpes. So being a bit creative and coming up sexual activity that is reasonably acceptable to both parties such that both FCs can feel OK. Then the damage that could be caused to the relationship can be avoided.

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Suicide risk assessment

In suicide risk assessment one of the factors that is commonly reviewed is what high risk behaviour does the individual engage in. If the person repeatedly engages in in high risk behaviour then that can indicate some degree of suicidal intent particularly with the two suicide decisions of

“I will kill myself by accident”

or

“I will get you to kill me”

In high risk behaviour often drug use is considered. However this is a problematic concept to consider because it is a highly politicised area and it is also an area where people can very easily respond to from their Parent ego state. Some have strong opinions about drugs and drug use and these they can at times mistake as being based on fact when it is opinion.

Risky?

If one is wanting to do a suicide risk assessment one needs to be very clear about the facts of the risk, not the politics or opinions about drug use risk. If not then one is going to make more faulty judgements about the suicide risk level for a person which obviously is a very undesirable thing.

The Australian Psychological Society in its position statement on drug use is clear that decisions about which drugs should be legal and illegal drugs are mainly political decisions not decisions based on health. This creates a problem for governments in that it has to pretend to the public that it is making a decision based on health and not for political expediency.

A good example of this comes with party drugs like ecstasy. When a young girl dies by overdose of ecstasy at a dance party it often is highly publicised and the face of a young girl gets shown over and over in the press. At the same time one hears public statements by police and senior health department officials. They will state that such drugs are risky because they are made in backyard laboratories with no control over what goes in them.

This is the truth, but not the whole truth. Thus we get the government spin on the risks of drug use, something that the suicide risk assessor must avoid. What they do not say is that the risk of taking ecstasy involves the same level of risk as getting on a plane and having it blown up by terrorists. It is low risk but the government can not let this be said.

However in my studies of this area I came across a very interesting risk assessment model developed by two academics at a London university. They have developed the following risk assessment model. These are based on UK annual mortality rates, so one could assume they would be relatively similar to countries like Australia and the United States.

Extremely high

Russian roulette.

Very high risk

Tobacco, methadone, injecting drug use, BASE jumping, grand prix racing, cancer, heart disease, space travel

Quite high

Heroin, Morphine, barbiturates, alcohol, hang gliding, parachuting, motorbike racing, sudden infant death, working in mining, Asbestos, strokes, prostrate cancer, shaking of babies, off shore oil work

Medium

Solvents, benzodiazepines, motor sports, water sports canoeing, diabetes, skin cancer, influenza, suicide, giving birth, helicopter travel. liposuction. working in farming, being in police custody, working in construction

Quite low

Ecstasy. MDMA, speed, cocaine, contraception pill, GBH, fighting sports, snow sports soccer & rugby, Asthma, AIDS. meningitis, cervical cancer, food poisoning, air travel, being murdered, chocking on food, electrocution, drowning, passive smoking, factory work

Very low

LSD, magic mushrooms, viagra, fair ground rides, swimming, riding sports, food allergies, syphilis, malaria, appendicitis, pedestrian crossings, clothes catching fire, falling out of bed, vaccination, abortion, storms, terrorism

Beauty

Extremely low

Marijuana, cannabis resin, indoor sports, playgrounds, peanut allergy, measles, insect stings, copulation, starvation, dogs, lightening, nuclear radiation, police shootings

Negligible

Caffeine, nitrous oxide, ketamine, computer games, masturbation, small pox, leprosy, sharks, UFOs, cats, meteorites, executions, volcanoes

Thus if a government was to make high risk or more lethal drugs illegal and the low risk drugs legal, like they claim to be, them one would see some significant legislative changes indeed! (And please don’t mention to me about marijuana induced psychosis as the science on it is very dodgy at best, see the blog postings on my website. Another major area of government spin)

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Self harm blog (Editted)

For an interesting blog on self harm have a look at Sarah's Blog

She was kind enough to answer some questions I had and came up with some interesting material that provides more insight into this area.

I have made some comments about it but I will not post them until she has given approval. So this maybe editted later.

Case study 4.

Stone (2009) states, “I started to deliberately injure myself when I was in my mid teens.... When it came to my last year of Uni it really reared it’s ugly head as an addiction, one that came with an almost unbearable amount of emotion. I was so stressed out because of the pressure of my studies that I was thinking up ways to harm myself, but I couldn’t face the thought of someone else finding out that I had actually done this to myself.” (Paragraphs 11 - 12)

A follow up interview of the individual which was placed on the internet. “T” is myself and “S” is part of the response from the interviewee

Stone (2010) states, “T = Can you describe the type of self harming that you did , was there a ritual involved and so forth?

S = No there wasn’t a ritual that I followed, they were all separate events with sometimes weeks or a couple of months in between them as the stress built up. I felt in a very particular kind of mind set each time though and one which I came to recognise over the years. I didn’t self harm in the stereotypical way that one hears about these days, as I’ve said in my original post I’d never heard of the term or knew that anyone else did anything at all similar. I certainly considered hurting myself with blades etc but always wussed out! Now that I think about it punching or inflicting pain with a blunt tool such as a hair brush or edge or a piece of furniture was by far my preference. This created bruising rather than cuts as I felt it easier to do to myself. Twice I created a scene that appeared as though I’d passed out and made sure that I was found by someone. This had a similarly good feeling as it caused people to be really concerned for myself and give me some attention. Other times I created bruising and lied about how I had got them, pretending that I’d been beaten up or similar.

T = How the actual relief came. Was it before, during or after the actual act of self harming? And was their thinking about the self harming going on in your head at that time of self harming and if so what was it?

S = When I was inflicting the bruising at first it hurt but after a few minutes it almost became easy as I guess I became used to the pain and managed to block it out. This allowed me to continue inflicting this injury on myself long after I otherwise could have beared I think. It felt good to actually hurt myself like that, in doing it I felt some form of relief, but with it came a huge chunk of guilt knowing that what I was doing wasn’t good, but the ‘need’ to do it was far stronger than any feelings that tried to make me feel bad about doing it. Having created the injury I then liked telling people about it, lying all the time obviously, but their compassion made me feel good so the more people I told the better I felt about it. I certainly don’t go by ‘the end justifies the means’ ideas at all on the whole but in this case that went out the window! It was a completely cold calculated decision that I made each time. I didn’t consider the long term effects of what all the deception was doing to me or others, or whether this was a long term solution, it just went round and round my own head as I didn’t let anyone in on any of it.” (Paragraphs 10 - 13)

“T = I assume you don’t self harm now, so what changed?

.....So I have no need to hurt myself any more. When I’m stressed about something I talk it through with my husband, Mum, sister or close friend before it becomes a big issue. I look at the issue as objectively as I can, ask their opinions about it, weigh them up, ask God for His opinion on it and act from there. If it’s something that needs resolving that can be then I act in the way that I consider best, but if it’s just one of those things that you’ve got to just grin and bear it knowing that there’s an end in sight then I just get on with it. If I find that I’m still getting stressed I talk more about it, eat some chocolate, have a long bath, do some exercise – in fact anything rather than just sit and stew about it!” (Paragraphs 15 & 17)

This case study has some interesting clinical features. The most common methods of self harm tend to be cutting, burning and perhaps wound interference. In this instance we have an example of hitting self such that one bruises. As with other types of self harm there is an addictive quality reported thus indicating that her Child ego state is obtaining a significant psychological benefit from the activity. She reports the benefit as a sense of relief and she is using the self harm mainly as a means of tension relief.

Excluded Child ego state

Also reported is a particular kind of mind set prior to the punching and bruising. From a counseling point of view this is important as it indicates the build up period prior to self harm and one would enquire as to what that mind set was. Once defined one can then use it as an alarm system such that the individual can develop a Plan B to be used at that time with the hope of avoiding the self harm. Plan B being alternative ways to relieve tension and stress. Also from a counseling point of view she reports being able to block out the pain which means that she is capable of significant exclusion of the Child ego state as is shown in diagram 2. Treatment would need to include at some point an opening up of the Chile ego state feelings again. However they have been repressed for some time and for some good psychological reason if she agrees to open up the feelings again then she may come across some feelings which may be quite painful.

This case study also demonstrates how the different motives for self harming are not mutually exclusive. As indicated she self harmed as a means to reduce tension and she also mentions that she self harms as a way of obtaining attention from others. In addition to this we see that she self harms as a means to get nurturing in this instance from others. She reports liking the concern and compassion shown by others and reports regularly seeking these responses from others.

This shows the possible initial development of a condition like Munchausen Syndrome. By self harming she can adopt the sick or injured role with others then giving her nurturing and compassion. In this instance, as she matured she subsequently developed other means of seeking compassion and nurturing from others. If that had not happened then she may have developed fully fledged Munchausen Syndrome symptoms. In her last paragraph she explains how she now deals with stress and distress in ways other than self harming. She seeks out family and friends to talk to and get support from which is the psychologically healthy way to deal with stress and thus any Munchausen Syndrome symptoms have no need to develop.

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The Don’t be close injunction

With this injunction the young child perceives the parents to be telling it that for some reason closeness is not OK, dangerous or for some unstated reason not a good thing. This can include both physical and psychological closeness. In particular these people have trouble with emotional intimacy, emotional closeness and so forth.

If this is one of the person’s core injunctions as they are sometimes called then their life will be such they end up alone. As their life script plays out slowly and surely they will have less and less contact or at least meaningful contact with others and basically end up a loner as Eric Berne would say.

This is usually achieved in one of two ways. Firstly the person will continually find reasons to withdraw from others and relationships. This can be done because they feel they are not worthy or that the other person is in some way not acceptable or worthy and thus they withdraw from the relationship. This happens over and over such that eventually there are not many relationships left in the person’s life.

The other way to end up alone is to use anger. Anger separates people psychologically and often geographically as well. If one is angry then others will tend to drift away, if not leave directly. When a couple presents for counselling and report ongoing angry conflict the first thing one looks for is the intimacy between them.

If one or both of them have a Don’t be close injunction then they will feel uncomfortable about closeness and intimacy and showing love and so forth. One good way to avoid such things is to be angry at each other. Anger is a great way to avoid emotional intimacy.

Can someone have a Don’t be close

injunction and get knocked up?

Do I have a Don’t be close injunction

Relationships are very much a half glass full or a half glass empty type of thing, it depends on how you look at them. There is always some problem in any relationship so do you look at relationships in a way where you are looking for solutions or looking for reasons why it wont work.

Do you accumulate others or tend to repel them. Do you tend to be an inclusive type of person like this:

Or tend to do this with relationships:

What happens to your relationships with others? Do they tend to fade away or does there tend to be a disagreement or bust up of some kind.

How many people do you dislike and would seek to avoid if you could. Is the list long or short? Can you forgive and forget in relationships and again be friends with someone whom you felt mistreated you in some way in the past.

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Help

I am writing a book on suicide and self harm and unfortunately my artistic skills are not too good. I need a drawing of the Langer's lines on the body to assit with harm minimization of those who self harm by cutting.

Here are two drawings I got from the internet but I can't use them as they are copyrighted.

Is there any drawing type of person out there who could draw one for me and then give me permission to use it? It does not need to be as detailed as the top diagram. The detail of the bottom one is probably just right.

I would need it to be no more than 10cm high, in black and white and if I could get the original and maybe as a JPEG. I can scan it as well.

Your help would be greatly appreciated.

Thanks in anticipation

Tony

Childhood maltreatment

Well folks we can all breathe a sign of relief. Science has spoken, that bastion of truth, honesty, factuality and knowledge has given us its decision. Now we can all go out can pontificate that university studies have shown, scientific evidence suggests Freud was right.

The September 2009 edition of the ‘Australian Psychologist’ journal is a theme edition on Childhood Maltreatment. The lead article by Carr and Francis(2009) reports their research and provides a literature review of the science in this area. They state that there is a “..large body of literature showing an association between childhood maltreatment and PDs. (Personality disorders)” (P151). This has been shown to be the case in both retrospective and longitudinal studies.

How you are treated in childhood effects your subsequent level of psychological maladjustment or lack of it. Science has spoken -- YaaaaaY!!. Adverse child hood experiences can result in emotional problems like personality disorders, anxiety, depression and so forth.

Not uncommonly in the area of childhood maltreatment one finds people distinguish between physical abuse, sexual abuse and emotional abuse. This research found no significant differences between them. There is an assumption by some that physical and sexual abuse are more psychologically damaging than emotional abuse whereas the research suggests this is not the case. REDRESS WA may indeed make this assumption and give more compensation to those who suffered physical and sexual abuse whilst in state care compared to those who “only” suffered emotional abuse.

As counsellors hear clients say from time to time, “I wish she had hit me”. Emotional abuse is much less tangible than a physical hit and this can at times cause the child more angst and difficulties than if the abuse had been more clear with physical hits.

Thus they conclude, “These results also lend support to aetiological theories that link the development of PDs to childhood maltreatment”(P153). University studies now prove that Freud was right! Well maybe not all of his theories right but they support his primary assumption that our childhood experiences effect us psychologically throughout life. Maltreatment in childhood can lead to anxiety, depression in adulthood,

This of course lends support to the psychodynamic theories of psychopathology. Those who claim that personality disorders, anxiety and depression have nothing to do with early childhood experiences now have a large body of science to respond to.

Also in this theme issue was a paper on foster care and recovery from childhood maltreatment. It was stated that there is a large and growing body of evidence that children removed from abusive homes into foster care have a poor psychological outcome in the long term. Whilst it is acknowledged that a children can and do learn some good attachment skills in foster homes there is the very real possibility of negative outcomes as well.

However it was also stated that comparing outcomes from foster homes to outcomes of children who were removed to orphanages then the results are even worse. Children removed to orphanages tended to be psychologically worse off than those moved to foster homes. Again this could have implications for compensation paid through REDRESS WA.

I recall going to a seminar recently given by a well known psychiatrist who spoke on child sexual abuse. He stated that the science is emphatic. A child who discloses sexual abuse to parents (or others) and then is reported to the police that child will be psychologically worse off at the end of the process whether it ends up in court or not and no matter how well it is dealt with.

You can’t get much more of a dramatic collision between the needs of an individual child and the needs a of a society. For the child it is better if it is dealt with in house and not with the police but the society suffers. If the police are informed it is better for the society but the child is worse off.

Family attachments need to

be handled with great care

With Australia’s new mandatory reporting of child sexual abuse laws the needs of the society are being given more importance. What this will do psychologically to a generation of children we will have to wait and see. The money required to deal successfully (or at least to minimise as much damage as possible) with the children of such mandatory reporting is simply too large and will never eventuate, we will see what the long term outcome is.

It also provides further evidence of the power of human attachment. A child will attach to its primary parenting figure whether it is being abused or not. The need to attach clearly outweighs the child’s assessment of the parental treatment afforded it. An attachment allows a child to define who it is at its very core and its basic sense of self. Thus one needs to be very careful how the child is removed from such a parent such that the child is not worse off and more damaged.

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