Mindfulness therapy comes at a high price for some, say experts

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anxiety, attention, breath, depersonalisation, Depression, health professionals, meditation, mindful living, mindfulness, mindfulness meditation, mindfulness therapy, mindfulness-based cognitive therapy (MBCT), NHS, side-effects, stress, teachers, training, trauma memories, vulnerability

Mindfulness therapy comes at a high price for some, say experts

In a first floor room above a gridlocked London street, 20 strangers shuffle on to mats and cushions. There’s an advertising executive, a personnel manager, a student and a pensioner. A gong sounds softly and a session of sitting meditation begins. This is one of more than 1,000 mindfulness courses proliferating across the UK as more and more people struggling with anxiety, depression and stress turn towards a practice adapted from a 2,400-year-old Buddhist tradition.

Enthusiasm is booming for such mindfulness-based cognitive therapy (MBCT) courses, which an Oxford University study has found can reduce relapses into depression by 44%. It is, say the researchers, as effective as taking antidepressants. It involves sitting still, focusing on your breath, noticing when your attention drifts and bringing it back to your breath – and it is surprisingly challenging.

Lifestyle magazines brim with mindfulness features and the global advertising giant JWT listed mindful living as one of its 10 trends to shape the world in 2014 as consumers develop “a quasi-Zen desire to experience everything in a more present, conscious way”.

But psychiatrists have now sounded a warning that as well as bringing benefits, mindfulness meditation can have troubling side-effects. Evidence is also emerging of underqualified teachers presenting themselves as mindfulness experts, including through the NHS.

The concern comes not from critics of mindfulness but from supporters, such as Dr Florian Ruths, consultant psychiatrist at the Maudsley hospital in south London. He has launched an investigation into adverse reactions to MBCT, which have included rare cases of “depersonalisation”, where people feel like they are watching themselves in a film.

“There is a lot of enthusiasm for mindfulness-based therapies and they are very powerful interventions,” Ruths said. “But they can also have side-effects. Mindfulness is delivered to potentially vulnerable people with mental illness, including depression and anxiety, so it needs to be taught by people who know the basics about those illnesses, and when to refer people for specialist help.”

His inquiry follows the “dark night” project at Brown University in the US, which has catalogued how some Buddhist meditators have been assailed by traumatic memories. Problems recorded by Professor Willoughby Britton, the lead psychiatrist, include “cognitive, perceptual and sensory aberrations”, changes in their sense of self and impairment in social relationships. One Buddhist monk, Shinzen Young, has described the “dark night” phenomenon as an “irreversible insight into emptiness” and “enlightenment’s evil twin”.

Mindfulness experts say such extreme adverse reactions are rare and are most likely to follow prolonged periods of meditation, such as weeks on a silent retreat. But the studies represent a new strain of critical thinking about mindfulness meditation amid an avalanche of hype.

MBCT is commonly taught in groups in an eight-week programme and courses sell out fast. Ed Halliwell, who teaches in London and West Sussex, said some of his courses fill up within 48 hours of their being announced.

“You can sometimes get the impression from the enthusiasm that is being shown about it helping with depression and anxiety that mindfulness is a magic pill you can apply without effort,” he said. “You start watching your breath and all your problems are solved. It is not like that at all. You are working with the heart of your experiences, learning to turn towards them, and that is difficult and can be uncomfortable.”

Mindfulness is spreading fast into village halls, schools and hospitals and even the offices of banks and internet giants such as Google. The online meditation app Headspace now has 523,000 users in the UK, a threefold increase in 12 months. But mounting public interest means more teachers are urgently needed and concern is growing about the adequacy of training. Several sources have told the Guardian that some NHS trusts are asking health professionals to teach mindfulness after only having completed a basic eight-week beginners’ course.

“It is worrying,” said Rebecca Crane, director of the Centre for Mindfulness Research and Practice in Bangor, which has trained 2,500 teachers in the past five years. “People come along to our week-long teacher training retreat and then are put under pressure to get teaching very quickly.”

Exeter University has launched an inquiry into how 43 NHS trusts across the UK are meeting the ballooning demand for MBCT.

Marie Johansson, clinical lead at Oxford University’s mindfulness centre, stressed the need for proper training of at least a year until health professionals can teach meditation, partly because on rare occasions it can throw up “extremely distressing experiences”.

“Taking the course is quite challenging,” she said. “You need to be reasonably stable and well. Noticing what is going on in your mind and body may be completely new and you may discover that there are patterns of thinking and acting and behaving that no longer serve you well. There might be patterns that interfere with living a healthy life and seeing those patterns can bring up lots of reactions and it can be too much to deal with. Unless it is handled well, the person could close down, go away with an increase in self-criticism and feeling they have failed.”

Finding the right teacher is often difficult for people approaching mindfulness for the first time. Leading mindfulness teaching organisations, including the universities of Oxford, Bangor and Exeter, are now considering establishing a register of course leaders who meet good practice guidelines. They expect mindfulness teachers to train for at least a year and to remain under supervision. Some Buddhists have opposed the idea, arguing it is unreasonable to regulate a practice rooted in a religion.

Lokhadi, a mindfulness meditation teacher in London for the past nine years, has regular experience of some of the difficulties mindfulness meditation can throw up.

“While mindfulness meditation doesn’t change people’s experience, things can feel worse before they feel better,” she said. “As awareness increases, your sensitivity to experiences increases. If someone is feeling vulnerable or is not well supported, it can be quite daunting. It can bring up grief and all kinds of emotions, which need to be capably held by an experienced and suitably trained teacher.

“When choosing a course you need to have a sense of the training of the teacher, whether they are supervised and whether they themselves practise meditation. Most reputable teacher training courses require a minimum of two years’ meditation practice and ensure that teachers meet other important criteria.”

We must identify girls at risk from gangs

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gangs, isolation, risk, self-harm, sexual abuse, sexual exploitation, vulnerability

We must identify girls at risk from gangs

When I met Rita she was 17 and in custody for the 13th time. Her offending had escalated from moped theft and “antisocial” behaviour with boys when she was 11, through to firearms possession. She had been self-harming for the past three years, had contracted chlamydia, was malnourished, had developed an addiction to crack cocaine, and was being sexually exploited by the street gang to whom she was associated.

This had not happened to Rita overnight. It was the consequence of years of exploitation by her male peers, isolation from her friends, exclusion from school, and being sexually abused by a family member when she was eight years old. From a young age, a myriad of professionals had opportunities to intervene and protect Rita, but, instead, her risk snowballed.

A report published this week by the Centre for Mental Health demonstrates that Rita’s case is not a one-off. The report is based on data from 8,000 10- to 18-year-olds, who, following their arrest between August 2011 and November 2012, were screened for 29 different risk factors and health issues, such as family conflict, homelessness and victimisation, as part of a study to identify the most appropriate interventions. The screening process was a pilot run in 37 areas of England. Gang-involved girls were found to be over nine times more likely to exhibit 19 or more of these risk factors than the other young people screened.

Gang-involved girls navigate harmful environments and relationships. According to the study, young women who had “histories of parental imprisonment, poor parental mental health, parental substance misuse, or neglect” were three to five times more likely to be gang-involved than other girls who were screened. In addition, they were three times more likely to be identified as victims of sexual abuse and four times more likely to have been excluded from school.

The same girls were also more likely to have difficulties with their physical and mental health and wellbeing than other young people screened. Like Rita, 30% were reported to be self-harming or at risk of suicide, and were over three times more likely to have sexual health needs.

When public attention is focused on the horrendous accounts of groups of adult men sexually exploiting girls around the country, it is easy to forget about girls and young women who are at risk from their peers. The information provided clearly demonstrates that risk can be present in homes, peer groups, schools, neighbourhoods and in wider society, which increases the vulnerability of girls to street gangs. This report provides a statistical backdrop to the accounts given to me by hundreds of women and girls during the Female Voice in Violence project; now it is time to turn the stories and figures into action.

From preventing vulnerability, to the identification of girls linked to gangs, through to the programmes delivered to support them, and routes of safety that are offered, our processes need to be gender-specific. This groundbreaking report throws into sharp relief the impact of gang-association and the opportunities that exist to intervene across a young woman’s lifetime. Of the girls that were screened, 73% engaged with an intervention that was offered to them. It is critical that all agencies who work with girls and young women use the evidence to mobilise and evaluate interventions that will better identify and protect those involved with gangs.

Soldiers more likely to be convicted of violent offences, report reveals

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alcohol abuse, anger, anxiety, armed forces, combat, Depression, mental health issues, Military, military personnel, PTSD, support, trauma, treatment, troops, veterans, violence, violent behaviour, violent offence, vulnerability

Soldiers more likely to be convicted of violent offences, report reveals

Young British men who have served in the armed forces are three times more likely to have been convicted of violent offences than their civilian peers, according to a study published on Friday.

The report in the Lancet, the first to marry the experiences of almost 14,000 military personnel with details on the Police National Computer, also shows how troops who have been in combat are more likely to be involved in violent offending back in the UK.

The study’s authors believe this raises questions about how the military and the NHS supports serving and former troops, some of whom end up abusing alcohol or developing severe mental health illnesses following tours in Iraq and Afghanistan.

Drawing on a random sample of 13,856 serving and ex-personnel mostly from the army, researchers from King’s College London looked at criminal offending rates and the possible links between them and post-traumatic stress disorder, anxiety, depression and other mood disorders.

The study found that of 2,700 men serving in the armed forces under the age of 30, 20.6% had been convicted of a violent offence, compared with 6.7% in the general population. Men who had seen combat in Iraq and Afghanistan were 53% more likely to commit a violent offence than those in non-frontline roles. And personnel who had multiple experiences of combat had a 70% to 80% greater risk of being convicted of acts of violence.

Violent offences covered a broad range of acts, from verbal harassment to homicide. They did not include incidents of domestic violence.

“More frequent exposure to traumatic events during deployment increased the risk of violent offending,” the report says. “We noted a strong link between PTSD and violent offending. Combat veterans with PTSD and other mental health concerns frequently present with problems of anger and aggression.” However, it also notes that troops who volunteer and are trained for fighting are not chosen randomly.

“In the UK, infantry units have traditionally promoted aggression as a desirable trait and such units frequently recruit individuals who are socially disadvantaged and are likely to have low educational attainment.”

Dr Deirdre MacManus, who led the study, said: “Our study found that violent offending was most common among young men from the lower ranks of the army and was strongly associated with a history of violent offending before joining the military. Serving in a combat role and traumatic experiences on deployment also increased the risk of violent behaviour.”

Prof Sir Simon Wessely, who co-authored the study, added: “We are suggesting there is a problem that needs to be looked at, but just as with post traumatic stress disorder this is not a common outcome in military populations.”

Screening within the armed forces to identify at-risk individuals would not work, he argued. For every correct prediction there were likely to be five that were wrong.

Dr Walter Busuttil, director of medical services at Combat Stress, said: “These findings will help us to identify which veterans are most vulnerable and in need of appropriate care and treatment after leaving the armed forces. We are planning courses for anger management and domestic violence. We are about to establish programmes that deal with alcohol abuse linked to PTSD.

“It would be grossly unfair and inaccurate to characterise all veterans living with PTSD as potential criminals. As noted in the report the vast majority [83%] of serving and ex-serving UK military personnel do not have any sort of criminal record, and the likelihood of violent behaviour is lower among older veterans [aged over 45] than in the general population. What we require now is continued public education to reduce any negative connotations with seeking help for mental health issues, as well as sustained funding for services for veterans.”

The Ministry of Defence has introduced a series of initiatives to encourage serving personnel to come forward if they fear they might be suffering from trauma or the early stages of anxiety or depressive illness, and has committed £7m to improve support services.

What doesn’t kill us…

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adversity, autonomy, avoidance, cognitive processing, compassion, coping, distress, family, friends, gratitude, Grief, intrusion, measures, personal growth, positive changes, post-traumatic growth, post-traumatic stress, psychologists, psychology, PTSD, relationships, resilience, self-acceptance, Self-esteem, support, theory, trauma, vulnerability, well-being

What doesn’t kill us…

The field of psychological trauma is changing as researchers recognise that adversity does not always lead to a damaged and dysfunctional life. Post-traumatic growth refers to how adversity can be a springboard to higher levels of psychological well-being. This article provides an overview of theory, practice and research. To what extent is post-traumatic stress the engine of post-traumatic growth? How can clinicians measure change? What can help people to thrive following adversity?

Suffering is universal: you attempt to subvert it so that it does not have a destructive, negative effect. You turn it around so that it becomes a creative, positive force.
Terry Waite, who survived four years as a hostage in solitary confinement (quoted in Joseph, 2012, p.143)

Scientific interest in positive changes following adversity was sparked when a handful of studies appeared in the late 1980s and early 1990s, reporting positive changes in, for example, rape survivors, male cardiac patients, bereaved adults, survivors of shipping disaster, and combat veterans. Then, the topic of post-traumatic stress disorder (PTSD) was relatively new (following its introduction in 1980 by the American Psychiatric Association), and was attracting much research interest. The relatively few observations of positive change were overshadowed by research on the ways in which trauma could lead to the destruction and devastation of a person’s life.

But interest in how trauma can be a catalyst for positive changes began to take hold during the mid 1990s when the concept of post-traumatic growth (Tedeschi & Calhoun, 1996) was introduced. It proved to be popular and became the descriptor for a field of inquiry attracting international attention from researchers, scholars and practitioners (see, Calhoun & Tedeschi, 2006; Joseph & Linley, 2008a; Weiss & Berger, 2010). Over the past decade it has developed into one of the flagship topics for positive psychology (Seligman, 2011). This article aims to provide a state-of-the-art review of the psychology of post-traumatic growth.

What is post-traumatic growth?
After experiencing a traumatic event, people often report three ways in which their psychological functioning increases:
1.    Relationships are enhanced in some way. For example, people describe that they come to value their friends and family more, feel an increased sense of compassion for others and a longing for more intimate relationships.
2.    People change their views of themselves. For example, developing in wisdom, personal strength and gratitude, perhaps coupled with a greater acceptance of their vulnerabilities and limitations.
3.    People describe changes in their life philosophy. For example, finding a fresh appreciation for each new day and re-evaluating their understanding of what really matters in life, becoming less materialistic and more able to live in the present.

Several self-report psychometric tools were published during the 1990s to assess positive changes following trauma, the first such measure was the Changes in Outlook Questionnaire (Joseph et al., 1993), followed by the Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996); the Stress Related Growth Scale (Park et al., 1996), the Perceived Benefit Scale (McMillen & Fisher, 1998), and the Thriving Scale (Abraido-Lanza et al., 1998). Each of these measures asks respondents to think about how they have changed since an event and to rate the extent of their change on a series of items.

Using such measures of perceived growth, and open-ended interviews, a large number of studies have shown that growth is common for survivors of various traumatic events, including transportation accidents (shipping disasters, plane crashes, car accidents), natural disasters (hurricanes, earthquakes), interpersonal experiences (combat, rape, sexual assault, child abuse), medical problems (cancer, heart attack, brain injury, spinal cord injury, HIV/AIDS, leukaemia, rheumatoid arthritis, multiple sclerosis) and other life experiences (relationship breakdown, parental divorce, bereavement, emigration). Typically 30–70 per cent of survivors will say that they have experienced positive changes of one form or another (Linley & Joseph, 2004).

Practitioners in health, clinical and counselling psychology will encounter patients daily whose lives have been affected by such events. Up to now practitioners may have drawn on theories of post-traumatic stress to help their patients. A pressing theoretical issue therefore is the relation between post-traumatic stress and post-traumatic growth. How can these new ideas improve how we work with patients?

Theory and practice of post-traumatic growth
Research is now untangling a seemingly intricate dance between post-traumatic stress processes and post-traumatic growth. The most successful attempt to date is organismic valuing theory, which explains how post-traumatic growth arises as a result of post-traumatic stress. This is a person-centred theory that draws together information processing and social cognitive theories of post-traumatic stress with research on self-determination theory. The theory shows trauma leads to a breakdown in self-structure, signalled by the experiences of post-traumatic stress indicating the need to cognitively process the new trauma-related information. People are intrinsically motivated towards processing the new trauma-related information in ways that maximise their psychological well-being (Joseph & Linley, 2005, 2006).

Organismic valuing refers to how intrinsic motivation is experienced by the person. One woman who was caught up in a fatal shooting in which her close friend was killed, and who had suffered from considerable post-traumatic stress for several years, said how she woke early one morning after a night of restless sleep and got up to look at a picture of her children:

In the silent wee hours of the morning, I sat staring at their picture and began to sob. Through my sobs, I heard the real voice of wisdom I believe we all possess. It was my voice, the voice that knows me best, but a voice that had become muted. Guess what. No one is coming to change the situation. No one will rescue you. No one can. It’s up to you. Find your strength. I realised that as long as I remained a victim, I too made my family a victim. My anxiety could only teach them to be anxious. I was robbing them of happiness and a positive outlook on the world. I had come to the intersection of intersections. I could choose to end my life or I could choose to live. I needed to live for my family – and later I understood most importantly, for myself. (quoted in Joseph, 2012, p.142)

Post-traumatic growth involves the rebuilding of the shattered assumptive world. This can be illustrated through the metaphor of the shattered vase. Imagine that one day you accidentally knock a treasured vase off its perch. It smashes into tiny pieces. What do you do? Do you try to put the vase back together as it was? Do you collect the pieces and drop them in the rubbish, as the vase is a total loss? Or do you pick up the beautiful coloured pieces and use them to make something new – such as a colourful mosaic? When adversity strikes, people often feel that at least some part of them – be it their views of the world, their sense of themselves, their relationships – has been smashed. Those who try to put their lives back together exactly as they were remain fractured and vulnerable. But those who accept the breakage and build themselves anew become more resilient and open to new ways of living.

These changes do not necessarily mean that the person will be entirely free of the memories of what has happened to them, the grief they experience or other forms of distress, but that they live their lives more meaningfully in the light of what happened.

The implication of organismic valuing theory is that post-traumatic stress is the catalyst for post-traumatic growth. Helgeson et al. (2006) conducted a meta-analytic review concluding that greater post-traumatic growth was related to more intrusive and avoidant post-traumatic stress experiences. As intrusion and avoidance are generally seen as symptoms of PTSD at first glance this result would seem to suggest that post-traumatic growth is indicative of poor mental health, but consistent with organismic valuing theory Helgeson et al. suggest is that these constructs reflect cognitive processing:
Experiencing intrusive thoughts about a stressor may be a signal that people are working through the implications of the stressor for their lives, and these implications could lead to growth. In fact, some might argue that a period of contemplation and consideration of the stressor is necessary for growth to occur. (p.810)

It is in this sense that post-traumatic stress can be conceptualised as the engine of post-traumatic growth. This is also the conclusion of a recent study by Dekel and colleagues (2012), who set out to shed light on the interplay between PTSD and post-traumatic growth. Using longitudinal self-report data from Israeli combat veterans who were studied over 17 years, with assessment at three time points, the researchers found that greater PTSD in 1991 predicted greater growth in 2003, and greater PTSD in 2003 predicted greater growth in 2008.
However, it also seems that the relationship between post-traumatic growth and post-traumatic stress is a function of the intensity of post-traumatic stress. Butler et al. (2005), for example, in their study following the attacks of September 2001, found that greater post-traumatic stress was associated with greater post-traumatic growth, but only up to a point, above which post-traumatic growth declines.

Could there be a curvilinear relationship between post-traumatic stress and post-traumatic growth? Low levels of post-traumatic stress reactions indicate that the person has been minimally affected, thus one would expect minimal post-traumatic growth. A moderate level of post-traumatic stress is indicative that the individual’s assumptive world has in some way been challenged triggering the intrusive and avoidant experiences, but the person remains able to cope, think clearly, and engage sufficiently in the necessary affective-cognitive processing needed to work through. A high level of post-traumatic stress, however, where a diagnosis of PTSD might be considered, is likely to mean that the person’s coping ability is undermined and their ability to affectively-cognitively process and work through their experience is impeded. The inverted U-shape relationship between post-traumatic stress and post-traumatic growth has been reported in several studies (e.g. Kunst, 2010).

Thus, through the above research and theory we are developing a new understanding of psychological trauma that integrates post-traumatic stress and post-traumatic growth within a single conceptual framework which can guide clinical practice. A new constructive narrative framework that can guide practitioners is the THRIVE model (Joseph, 2012). THRIVE consists of six signposts (see box). Starting with ‘taking stock’, the therapist works with the client to alleviate problems of post-traumatic stress sufficiently so as to enable them to engage in effortful cognitive processing. Then follows five further signposts in which the therapist can work alongside the client. Post-traumatic growth provides practitioners with a new set of tools in their armoury for working with traumatised patients. 

New directions
Each of the measures mentioned above provides a particular operational definition of the construct, and they tend to be only moderately inter-correlated. Unlike, for example, the construct of post-traumatic stress disorder, which has an agreed definition provided by DSM around which measurement tools can be developed, there is no gold standard definition of post-traumatic growth. One suggestion arising from organismic valuing theory is to reframe post-traumatic growth as an increase in psychological well-being (PWB) as opposed to subjective well-being (SWB) (Joseph & Linley, 2008b). Traditionally, the focus of clinical psychology has been on SWB, which can be broadly defined as emotional states. Clinical psychology has been largely concerned with the alleviation of negative emotional states. With positive psychology in the background, clinical psychologists are now also concerned with the facilitation of positive emotional states. But post-traumatic growth does not refer to a positive emotional state but to an increase in PWB, defined as high levels of autonomy, environmental mastery, positive relations with others, openness to personal growth, purpose in life and self-acceptance (see box).

The topic of post-traumatic growth has also attracted interest from quantitative researchers in personality and social psychology. People may say they have grown, but have they really? There is a limitation to the above-mentioned measures, which is that they rely on retrospective accounts of change – that is, asking people to report on what positive changes they perceive themselves to have experienced since an event. We might refer to this as perceptions of growth to distinguish from actual growth, as measured by calculating the difference between state measures of psychological well-being before and after trauma.

Research suggests that the strength of association between actual and perceived growth is moderated by the degree of distress: for those who are most distressed there is a weaker correlation, but for those who are less distressed there is a moderate association (Gunty et al., 2011). It may be that perceptions of growth are at times illusory and a way of coping with distress (Zoellner & Maercker, 2006). Therefore researchers do need to be wary of always taking reports of growth at face value, particularly in the immediate aftermath of a crisis when people are most distressed.

However, while we may question people’s perceptions of growth, there is no question that actual post-traumatic growth occurs, as this has been demonstrated in before-and-after studies (e.g. Peterson & Seligman, 2003). What is now needed are more prospective longitudinal studies able to document the development of growth over time, how both actual and perceived growth co-vary over time and how they relate to other variables – both as outcome variables in order to understand the development of growth, and as predictor variables in order to understand the consequences of growth. Research shows that greater post-traumatic growth is associated with: personality factors, such as emotional stability, extraversion, openness to experience, optimism and self-esteem; ways of coping, such as acceptance, positive reframing, seeking social support, turning to religion, problem solving; and social support factors (Prati & Pietrantoni, 2009). But now more sophisticated theoretically informed designs are also called for in which we can begin to understand the factors that mediate and moderate post-traumatic stress and thus lead to post-traumatic growth. As an example of the directions that social and personality researchers may pursue, in one recent study it was found that emotion-focused coping mediated the association between subjective ratings of distress and post-traumatic growth and that emotional intelligence moderated
the association between emotion-focused coping and post-traumatic growth (Linley et al., 2011). While there is much that can be learned from quantitative research, there is also a need for qualitative research to explore new contexts (e.g. Splevins et al., 2011) and interventions (e.g. Hefferon et al., 2008).

Conclusion

The idea of post-traumatic growth has become one of the most exciting topics in modern psychology because it changes how we think about psychological trauma. Psychologists are beginning to realise that post-traumatic stress following trauma is not always a sign of disorder. Instead, post-traumatic stress can signal that the person is going through a normal and natural emotional struggle to rebuild their lives and make sense of what has befallen them. Sadly it often takes a tragic event in our lives before we make such changes. Survivors have much to teach those of us who haven’t experienced such traumas about how to live.

Box

THRIVE
Taking stock (Making sure the client is safe and helping them learn to manage their post-traumatic stress to tolerable levels, e.g. through exposure-related exercises).
Harvesting hope (Learning to be hopeful about the future, e.g. looking for inspirational stories of people who have overcome similar obstacles).
Re-authoring (Storytelling, e.g. using expressive writing techniques to find new perspectives).
Identifying change (Noticing post-traumatic growth, e.g. using the  Psychological Well-Being Post-Traumatic Changes Questionnaire  to track change).
Valuing change (Developing awareness of new priorities, e.g. positive psychology gratitude exercise).
Expressing change in action (Actively seeking to put post-traumatic growth into the external world, e.g. making a plan of activity for following week that involves doing concrete things).

BOX: Assessing growth
Think of how you yourself have been influenced by events in your own life. The Psychological Well-Being Post-Traumatic Changes Questionnaire (PWB-PTCQ) was developed to assess post-traumatic growth as defined by an increase in PWB. The PWB-PTCQ is an 18-item self-report tool in which people rate how much they have changed as a result of the trauma. A short six-item version is shown below.

Read each statement below and rate how you have changed as a result of the trauma.

5     = Much more so now
4     = A bit more so now
3     = I feel the same about this as before
2     = A bit less so now
1     = Much less so now

1.    I like myself
2.    I have confidence in my opinions
3.    I have a sense of purpose in life
4.    I have strong and close relationships in my life
5.    I feel I am in control of my life
6.    I am open to new experiences that challenge me

People may find it useful to use the PWB-PTCQ to gain insight into how they have changed. Often these dimensions of change go unnoticed in everyday life but deserve to be flagged up and nurtured. Clinicians will find the new tool useful as it allows them to bridge their traditional concerns of psychological suffering with the new positive psychology of growth following adversity (see Joseph et al., 2012).

Stephen Joseph is a Professor at the University of Nottingham and Honorary Consultant in Nottinghamshire NHS?Trust
stephen.joseph@nottingham.ac.uk

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Revealed: the scale of sexual abuse by police officers

Tags

abuse, Children, crime, police, rape, sexism, sexual assault, sexual harassment, sexual predators, vulnerability, women, young people

June 2012:

Revealed: the scale of sexual abuse by police officers

Sexual predators in the police are abusing their power to target victims of crime they are supposed to be helping, as well as fellow officers and female staff, the Guardian can reveal.

An investigation into the scale and extent of the problem suggests sexual misconduct could be more widespread than previously believed.

The situation raises questions about the efficacy of the police complaints system, the police’s internal whistleblowing procedures, the vetting of officers and a failure to monitor disciplinary offences.

Police officers have been convicted or disciplined for a range of offences from rape and sexual assault to misconduct in public office relating to inappropriate sexual behaviour with vulnerable women they have met on duty. Others are awaiting trial for alleged offences, though many are never charged with a criminal offence and are dealt with via internal disciplinary procedures.

The problem is to a large extent hidden, as no official statistics are kept and few details are released about internal disciplinary action in such cases.

By analysing the data available – including court cases and misconduct proceedings – the Guardian has attempted to document the scale of the corruption for the first time.

In the past four years, there were 56 cases involving police officers and a handful of community support officers who either were found to have abused their position to rape, sexually assault or harass women and young people or were investigated over such allegations.

The Independent Police Complaints Commission (IPCC) and the Association of Chief Police Officers (Acpo) are so concerned they are carrying out a rare joint inquiry into the scale of the problem, which will be published in September, the Guardian can reveal.

Their work was prompted by the case of the Northumbria police constable Stephen Mitchell, 43, who was jailed for life in January 2011 for carrying out sex attacks on vulnerable women, including prostitutes and heroin addicts, while he was on duty.

Despite being the subject of previous disciplinary offences, involving one inappropriate relationship with a woman and the accessing of the force computer to find private details of an individual, Mitchell had not been subjected to extra supervision or dismissed by the force.

Those targeted by the officers are predominantly women, but in some cases are children and young people, many of them vulnerable victims of crime.

The Guardian’s investigation has uncovered evidence of:

• Vetting failures, including a concern that vetting procedures may have been relaxed post-2001 during a surge in police recruitment.

• Concerns over the recording and monitoring of disciplinary offences as officers progress through their career.

• A tendency for women who complain they have been sexually attacked by a policeman not to be believed.

• A pervasive culture of sexism within the police service, which some claim allows abusive behaviour to go unchecked.

Debaleena Dasgupta, a lawyer who has represented women sexually assaulted and raped by police officers, said: “I don’t think any [victims] are quite as damaged as those who are victims of police officers.

“The damage is far deeper because they trusted the police and … believed that the police were supposed to protect them from harm and help catch and punish those who perpetrate it.

“The breach of that trust has an enormous effect: they feel that if they can’t trust a police officer, who can they trust? They lose their confidence in everyone, even those in authority. It is one of the worst crimes that can be committed and when committed by an officer, becomes one of the greatest abuses of power.”

The officers involved come from all ranks within the service: the most senior officer accused of serious sexual harassment was a deputy chief constable, who was subject to 26 complaints by 13 female police staff.

David Ainsworth, deputy chief constable of Wiltshire police, killed himself last year, an inquest heard this month, during an inquiry into his behaviour. He is one of two officers accused of sexual misconduct to have taken their own lives over the past four years.

In one of the worst cases in the past four years, Trevor Gray, a detective sergeant with Nottinghamshire police, broke into the home of a woman he met on a date and raped her while her young child slept in the house.Gray was jailed for eight years in May for rape, attempted rape and sexual assault.

Many of the cases documented involve police officers accessing the police national computer to gain access to the details of vulnerable women and young people in order to bombard them with texts and phone calls and initiate sexual contact.

Deputy Chief Constable Bernard Lawson of Merseyside police, the Acpo lead on counter-corruption, who is working with the IPCC on the joint report, said: “Police officers who abuse their position of trust have an incredibly damaging impact on community confidence in the service.

“There is a determination throughout policing to identify and remove those who betray the reputation of the overwhelming majority of officers.”

In its report on corruption within the police service published last month, the IPCC identified abuse of authority by officers for their own personal gain, including to engage in sexual intercourse with a vulnerable female while on duty, and the misuse of computer systems to access details of vulnerable females, as two of the five key corruption threats to the service.

IPCC figures show that 15% of the 837 corruption cases referred by forces to the watchdog between 2008 and 2011 involved abuse of authority by a police officer, and 9% involved misuse of systems.

Clare Phillipson, director of Wearside Women in Need, who supported some of Mitchell’s victims, said: “What you have here is the untouched tip of an iceberg in terms of sexually questionable behaviour and attitudes. The police service, in my experience, has an incredibly macho culture and women are seen as sexual objects.

“Police officers have a duty to steer away from vulnerable women in distress, some of whom see these police officers as their saviours. It is an abuse of their power to exploit that.”

One area to be examined by the IPCC is whether there might have been vetting failures from 2001 onwards during a massive recruitment drive in the police.

Between 2001 and 2007, the overall strength of the service grew by more than 16,000, with around 2,666 officers recruited each year on average.

Six years ago, a study of vetting within the police service by Her Majesty’s Inspectorate of Constabulary revealed “disturbing” failures that had allowed suspect individuals to join the service. The report, Raising the Standard, exposed more than 40 vetting failures among police officers and support staff. The report concluded: “The potential damage that can be caused by just one failure should not be underestimated.”

Update: Sexual predators in police ‘must be rooted out’

Time to lay responsibility at the rapist’s door

Tags

behaviour, blame, challenge, low self-esteem, perpetrators, prevention, rape, relationships, responsibility, Sexual Violence, support, Teens, vulnerability, women

Time to lay responsibility at the rapist’s door

A 15-year-old boy was describing to me and a group of 12 other young men his relationships with teenage girls. He held firm with his opinion that if a girl came round to his house it implied that she wanted to have sex. But there was one boy in the group who, even in the face of pressure from the others, was certain that “even if she’s naked, she’s not supposed to be raped”.

I was interviewing the young men about their experiences of relationships for the Female Voice in Violence project, and it was clear that the majority of the boys did not understand the concept of rape. They could not see it.

Would you “see” rape? This is the question being asked in the second stage of a government campaign to raise awareness of abuse in teenage relationships. The initiative is launched at a time when there is an increasing focus on young women’s experiences of sexual violence. To date, those shouldering the responsibility of rape prevention have been the victims: girls are blamed for making themselves vulnerable to rape, and their low self-esteem or a craving to belong is the reason, we are told, that they place themselves in situations where they may be victimised. Now, however, it is the turn of those who commit sexual violence to be challenged to recognise it.

It is right that girls are supported to reduce their vulnerability. However, there is a growing sense of frustration among girls, and some services that work with them, that this vulnerability is communicated as the cause of sexual violence. The message they hear is that girls are raped because they are vulnerable. Where, they ask, is the space to consider the responsibility of those who are perpetrating abuse? So a campaign that challenges the perpetrators to ask whether they see rape is welcome.

Girls have told me they are relieved that they are not once again being told to modify their behaviour in order to avoid abuse. Those same girls would call for services to support victims of sexual violence; these are essential. However, providing services to pick up the pieces, or reduce vulnerabilities, will never, on their own, prevent sexual violence. Until the behaviour of rapists is understood and challenged the abuse will continue.

The campaign signals a move to reframe and revisit questions about how to prevent sexual violence, so it is crucial that the response on the ground is able to mirror this. While investment has been made in services for boys and men who commit forms of violence such as gun and knife crime, little attention has been given to preventing their use of sexual violence. This needs to change.

Young people’s views are shaped by a mosaic of messages, images and attitudes. Professionals need to be supported to challenge these ideas in order to stem the development of abusive attitudes and behaviours.

Challenging the ideas that normalise sexual violence, from the outset, should underpin any such preventive work. The inclusion of men and boys in this debate is critical. The young man who condemned rape in the face of peer pressure is not a one-off. We need to understand the difference in attitudes between young men. Only then will we move from seeing rape to stopping it.

Not just a boy thing: how doctors are letting down girls with autism

Tags

aggression, anxiety, Depression, Eating Disorders, emotions, gender, mental health issues, misdiagnosis, OCD, relationships, social exclusion, stress, tics, vulnerability

Not just a boy thing: how doctors are letting down girls with autism

Annette Lewns has more experience than most of the different ways in which boys and girls with autism are treated. Her 14-year-old son, Ryan, was diagnosed when he was three and a half. But doctors refused to diagnose her 12-year-old daughter, Rachel, until she was nine.

“What angers me is that for years I was dismissed by doctors purely because Rachel was a girl. Ryan was spotted very quickly because the autism symptoms that doctors look for are so male-orientated,” said Lewns. “But Rachel’s autism was hidden unless you knew where to look for it.

“Rachel could express herself, she had a couple of friends and understood emotions if someone was at an extreme: really upset or really happy. But you didn’t really have to look too hard to see she didn’t genuinely understand emotions or relationships: she was just mimicking scripts and scenarios from TV.”

“The doctors failed time and time again to see through her coping strategies. I fought for years but I was confronted with a wall of disbelief and scepticism. They were simply unable to understand that a girl might present differently to a boy.”

While Ryan’s condition was acknowledged by their local authority, and he is now at a specialist school, Rachel continues to struggle at a mainstream school. “Ryan is being taught all sorts of tools and techniques to cope with his condition but Rachel is not,” said Lewns.

Estimates of the ratio of females to males diagnosed with Asperger’s syndrome or high-functioning autism varies from 1:4 to 1:10. No one understands this gender disparity: whether women really are less likely to be on the spectrum than men – or whether doctors are failing to spot the disorder in women.

Opinions are divided: Richard Mills, director of research at the National Autistic Society (NAS) says he “would not be surprised” if the true ratio was twice as high, with one woman on the spectrum for every two men. Dr Judith Gould, director of the NAS’s Lorna Wing Centre, thinks the ratio could be even narrower, with 1:1.5 female:male.

We may soon have an answer. Mills is leading the UK arm of a two-year international programme, Autism in Pink, which will look at the condition in women, focusing on the stress, social exclusion, vulnerability and misdiagnosis they suffer.

It follows concerns about reluctance to diagnose women. One recent survey by NAS found girls may wait longer than boys for a diagnosis and are more likely to be misdiagnosed: just one-fifth of girls with Asperger’s syndrome who responded to the survey were diagnosed by the age of 11, compared with half of boys.

The UK is leading the research side of the programme. Last week, Mills signed up the first two of the 12 women with Asperger’s he needs to work with researchers over a two-year period.

“I hope the programme will be the first step to ending the current trend for gender to be a barrier to diagnosis and post-diagnostic support,” he said. “Because research in the past has largely concentrated on males, the way we understand autism tends to be very much based on the experiences of men and boys with the condition. People are reluctant, for some reason, to make a diagnosis in girls and women.”

This reluctance is exacerbated by the fact that girls and women with Asperger’s or high-functioning autism can be more adaptive than boys: they are commonly better at hiding things or seeming more sociable, masking what doctors traditionally think of as the signs of autism.

But the strain of trying to appear “normal” can be immensely stressful. Gould said it results in “many of the girls we see having developed secondary problems such as anxiety, eating disorders or depression”.

This can also mean that misdiagnosis of girls and women is also a problem. The survey found 42% of females had been wrongly told they suffered psychiatric, personality or eating disorders, compared with 30% of males.

There is also the problem that the gender difference becomes a self-fulfilling prophecy: because more males are diagnosed than females, it is their symptoms and behaviours that experts have studied. The so-called screening tools, developed to help diagnosticians spot the syndrome, focus on culturally “male” interests, such as computers, trains and cars, rather than things more likely to appeal to a girl, such as animals, soap operas or fashion. Gould is rewriting the NAS’s diagnostic interview for social and communication disorders to include “gender-neutral” cues.

Even when an accurate assessment is given, however, it is no guarantee that the necessary support and help will materialise: the NAS survey found women continue to struggle after diagnosis, with half of females with Asperger’s or high-functioning autism – compared with 39% of males – saying it made no difference to the support they received.

Lucy Clapham, 25, spent years being turned away by doctors who insisted “girls don’t get autism” and told her to simply “act normal and read female magazines”. “I am certain that my diagnosis was delayed because of the fact that I am a girl,” she said. “My mum first noticed something when I was about six but our GP laughed at the suggestion. I’ve gone to counsellors, doctors and psychiatrists but all of them, including my teachers, refused to see I had classic autism even though I had casebook symptoms: almost no speech until I was five, no friends, hours spent staring at the washing machine, lining toys up and flicking my fingers in front of my eyes.”

When she was 12, Clapham became violent, aggressive and developed multiple tics, obsessions and compulsions. “I stopped talking outside of the house and sunk into an inner world,” she said.

After two more years and about eight counsellors, Clapham’s GP referred her to a child psychiatrist. “She was adamant that girls didn’t get autism, they just had ‘traits’,” said Clapham. “She claimed that I just needed to ‘act normal’ and that by buying nice clothes and reading women’s magazines I could learn to be ‘normal’. The only diagnosis I received from her was depression and anxiety.”

After leaving the children’s mental health service “none the wiser and possibly with more mental health problems than when I had arrived”, Clapham was sent to the adult mental health service and, after a long battle, to the Maudsley hospital in London, where she was finally diagnosed with autism, Tourette syndrome and obsessive-compulsive disorder.

“I was still refused services, however, partly because there were none available and partly because our local authority was not willing to fund an out-of-town, specialist autism service,” said Clapham. “I ended up getting sent to a college for the blind where I developed more mental health problems and became very aggressive because no one understood me or my autistic behaviour.

“When I was 20, I ended up in care because my mother couldn’t cope with my aggression and anxiety.”

Clapham stayed there for three years but still struggles. “Despite my diagnoses, some people still seem to believe that autism is a ‘boy thing’,” she said.

There is no clear understanding about how many girls and women are being missed – or wrongly diagnosed – and for how long. But that may soon change: the first neuroimaging analysis of women and men, with and without ASD, has been under way for the past two and a half years at King’s College’s Institute of Psychiatry (IoP) and the Autism Research Centre at the University of Cambridge. It’s hoped this research could provide the clues. The final stage of the project is about to begin, with results expected in months.

“It’s very exciting,” said Dr Michael Craig, a senior lecturer and honorary consultant at the IoP’s department of forensic and neurodevelopmental sciences. “We could well be looking at gender-specific treatments for Asperger’s being developed in quite a short period of time.”

What is autism?

First identified in the 1940s, autism is a developmental disability that lasts a lifetime and affects someone’s interaction with other people – how they communicate with and relate to them. It is a spectrum condition, affecting some more seriously than others. While some lead fairly independent lives, others suffer serious learning disabilities and need extensive support. Many who have an autism spectrum disorder can be badly affected because they have trouble processing sounds, sights and smells.

Around half a million people in the UK have autism, according to the National Autistic Society (NAS). What causes it is still unclear. “There is strong evidence to suggest that autism can be caused by a variety of physical factors, all of which affect brain development. It is not due to emotional deprivation or the way a person has been brought up,” the NAS says. Genetic factors are assumed to be responsible, and scientists are trying to pin down which genes are involved. Genetic testing to enable earlier diagnosis is therefore still a long way off.

Many people are not diagnosed until they reach adulthood. A recent NAS study of more than 8,000 people with autism, parents and carers found 52% were initially misdiagnosed. One in three adults with the condition say they have developed serious mental health problems because they have not received enough support to help them cope with the difficulties autism brings.