(hello) cloud mountain - sleepmakeswaves

Emerson

http://www.thepresentparticiple.blogspot.com

Key factors impacting on the mental health and well-being of refugees and asylum seekers in the resettlement context. - Luke Fullagar

Key factors impacting on the mental health and well-being of refugees and asylum seekers in the resettlement context.

Luke Fullagar

RMIT University 

 

Both refugees and asylum seekers in the resettlement context encounter a complex array of pre- and post-displacement factors that coalesce to affect their mental health and well-being (Porter & Haslam, 2005; Fernando, Miller & Berger, 2010).  Contemporary psychological research has sought to integrate an understanding of the range of crisis-related and daily stressors refugees and asylum seekers encounter at each stage in their journey toward safe and just living conditions (Miller & Rassmussen, 2010), and to study both the direct of these stressors as well as their unique interaction effects (Fernando, Miller & Berger, 2010). 

Early trauma-focused research assumed refugee psychopathology to directly result from pre-displacement exposure to pervasive, organised violence and persecution (Porter & Haslam, 2005). While accounting for a significant proportion of psychopathology and diminished well-being in a swathe of studies (e.g. Fox & Tang, 2000; Lopes Cardozo, et al., 2004; Neuner, Karunakara & Elbert, 2004), this direct-effects model has nevertheless been challenged by large variances in the degree to which disaster-related exposure accounts for PTSD symptom levels (3% to 99%) and depression symptom levels (3% to 86%) (Silove, 2009). While it is clear that pre-migration stress and trauma makes an important contribution to diminished mental health and well-being in refugee and asylum seeker populations, these results have prompted critiques that the direct-effects trauma-focussed model fails to adequately account for all dimensions of the refugee experience, typified by a diversity of persistent events across manifold dimensions of experience and which accumulate over pre-flight, flight, exile and resettlement situations (Porter & Haslam, 2005; Martin, 1994).

Counterbalancing the direct-effects model, psychosocial frameworks have sought to additionally offer perspectives on the contribution of 'daily' stressors that endure post-displacement (Miller & Rassmussen, 2010). These stressors include: in the pre-arrival phase; dangerous flight (e.g. dangerous terrain in unroadworthy vehicles or unseaworthy vessels), unsanitary temporary settlements, exposure to disease and poor access to healthcare, and the absence of privacy; and in the post-arrival phase; marginalisation, racism, socioeconomic disparity and disadvantage, inadequate housing, restrictions to labour market participation and access to capital, acculturation challenges including language inadequacies, loss of social and cultural supports, family disruption, isolation and separation anxieties, diminished social status, and cultural bereavement for loss of one's identified culture of origin (Eisenbruch, 1991; Porter & Haslam, 2005; Coffey, Kaplan, Sampson & Tucci, 2010; Sztompka, 2000; Silove, 1999; Birman et al., 2005).  In the Australian setting, these 'daily' stressors can also accumulate in long-term immigration detention – a situation which has been shown to participate in inducing and exacerbating extant distress, including depression, anxiety, demoralisation, low-concentration and memory disturbances (Coffey, Kaplan, Sampson & Tucci, 2010).  

Contemporary studies which have added these post-displacement concerns to pre-displacement trauma-exposure have repeatedly found that post-migration stressors account for equal, and at times greater, variance in depression; and significant, yet typically lesser, variance in PTSD symptoms (Ellis, MacDonald, Lincoln & Cabral, 2008; Gorst-Unsworth & Goldenberg, 1998; Montgomery, 2008; Miller & Rassumssen, 2010; cf Panter-Brick, et al., 2008). Moreover, these effects have been shown to interact – for example, in a study of Darfur refugees residing in Chad (Rassmussen et al., 2010), daily stressors of lacking basic needs and safety fully mediated the relationship between crisis-exposure and PTSD, and perceived safety mediated the relationship between crisis-exposure and functional impairment. In a study of internally displaced Sri-Lankans, (Fernando, Miller & Berger, 2010), evidence for a three-way mediation model was advanced – demonstrating direct effects of crisis-trauma on psychopathology, partial mediation whereby acute 'daily' stressors implicated in psychopathogy were exacerbated by crises, and further, a direct effect of daily stressors unrelated to the relevant crisis – together suggesting a complex arrangement of direct and interactional effects between crises and daily stressors which demand a multimodal treatment approach.

Taken together, the above trauma-focussed and psychosocial results also suggest that post-traumatic stress, while to be taken seriously, is not in all cases a predominant, or perhaps even inevitable, consequence of acute exposure to humanitarian crises, and that material and psychosocial support to remediate acute daily stressors may significantly assist resilient individuals regain psychological equilibrium in due course (Foa & Rothbaum, 2001; Bonanno, 2004; Miller & Rassumssen, 2010).  This has been used to inform integrated psychological therapies, and should inform future research in both repatriation and resettlement contexts (Miller & Rassumssen, 2010). Moreover, the role of material support, from government or private-sector social programs should not be underestimated in the design of integrated social policies complimenting these contemporary therapies. Indeed, Porter & Haslam's (2005) meta-analysis highlighted that in addition to personal factors, post-displacement material conditions moderated mental health outcomes, and that materially secure conditions, exemplified by permanent individual accommodation and economic opportunities, were significantly positively associated with enhanced psychological outcomes. Trans-disciplinary research into the psychological correlates of these sociological issues will remain a fruitful line of inquiry into key factors impacting refugees and asylum seeker mental health and well-being.

 

References

Birman, D., Ho, J., Pulley, E., Batia, K., Everson, M. L., Ellis, H., et al. (2005). Mental health interventions for refugee children in resettlement: white paper II. National Child Traumatic Stress Network. Retrieved on 20 October, 2012, from http://www.nctsnet.org/nctsn_assets/pdfs/promising_practices/ MH_Interventions_for_Refugee_Children.pdf. 

Bonanno, G. (2004). Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 202–208. 

Coffey, G., Kaplan, I., Sampson, R. & Tucci, M. (2010) 'The meaning and consequences of long-term immigration detention for people seeking asylum'. Social Sciences Australia, 70(12), 2070-2079.

Ellis, H., MacDonald, H., Lincoln, A., & Cabral, H. (2008). Mental health of Somali adolescent refugees: the role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184–193.

Eisenbruch M. (1991). From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Social Science and Medicine. 33, 673-679

Fernando, G., Miller, K., & Berger, D. (2010). Growing pains: the impact of disaster-relted and daily stressors on the psychological and psychosocial functioning of youth in Sri-Lanka. Child Development, 81(4), 1192-1210.

Foa, E., & Rothbaum, B. (2001). Treating the trauma of rape. New York: The Guildford Press.

Fox, S., & Tang, S. (2000). The Sierra Leonean refugee experience: traumatic events and psychiatric sequelae. Journal of Nervous and Mental Disease, 188, 490–495. 

Gorst-Unsworth, C., & Goldenberg, E. (1998). Psychological sequelae of torture and organized violence suffered by refugees from Iraq: trauma-related factors compared with social factors in exile. British Journal of Psychiatry, 172, 90–94.

Lopes Cardozo, B., Bilukha, O., Gotway Crawford, C., Shaikh, I., Wolfe, M., Gerber, M., et al. (2004). Mental health, social functioning, and disability in postwar Afghanistan. Journal of the American Medical Association, 292, 575–584.

Martin, S.F. A policy perspective on the mental health and psychosocial needs of refugees. In: Marsella, A.J., Bornemann, T.H., Ekblad, S., Orley, J., eds. Amidst Peril and Pain: The Mental Health and Well-Being of the World's Refugees. Washington, DC: American Psychological Association; 1994: pp 69-80.

Miller, K.E., & Rassumussen, A. (2010). War exposure, daily stressors and mental health in conflict and post-conflict settings: bridging the divide between trauma-focussed and psychosocial frameworks. Social Science and Medicine, 70, 7-16.

Montgomery, E. (2008). Long-term effects of organized violence on young Middle Eastern refugees' mental health. Social Science & Medicine, 67, 1596–1603.

Neuner, F., Karunakara, U., & Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, 72, 579–587.

Panter-Brick, C., Eggerman, M., Mojadidi, A., & McDade, T. (2008). Social stressors, mental health, and physiological stress in an urban elite of young Afghans in Kabul. American Journal of Human Biology, 20, 627–641.

Porter, M. & Haslam, N. (2005). Predisplacment and postdisplacement factors associated with mental health of refugees and internally displaced persons. Journal of the American Medical Association. 294, 602-612.

Rasmussen, A., Nguyen, L., Wilkinson, J., Vundla, S., Raghavan, S., Miller, K.E., & Keller, A.S. (2010). Rates and impact of trauma and current stressors among Darfuri refugees in Eastern Chad. American Journal of Orthopsychiatry, 80(2), 227-236.

Silove, D. (1999). The psychosocial effects of torture, mass human rights violations, and refugee trauma. Journal of Nervous and Mental Disease, 187, 200–207. 

Sztompka, P. (2000) 'Cultural Trauma: The Other Face of Social Change', The European Journal of Social Theory, 4, 449-466

Early Monitoring of Prodromal Symptoms in Bipolar Disorder

Early Monitoring of Prodromal Symptoms in Bipolar Disorder

Luke Fullagar

RMIT University

Early monitoring of prodromal symptoms has been included in numerous efficacious adjunctive psychosocial approaches to the treatment of bipolar disorders (e.g.  Family Focused Treatment (FFT) (Simoneau et al., 1999); Cognitive Behavioural Therapy (CBT) (Lam et al., 2000) (in both one-on-one (Lam et al., 2000; 2003; 2005) and group settings (Castle et al., 1997)); Interpersonal and Social Rhythm Therapy (IPSRT) (Frank et al., 1999); and Psychoeducation (Colom et al., 2003).

Prodromal symptoms emerge during the time between when symptoms are first recognised and when they reach an apex of severity (Molinar et al., 1988).  Because bipolar disorders involve a characteristic fluctuation in mood, behavior, and cognition, detecting and managing these symptoms during the early prodromal phase is critical and has been shown to assist in both preventing and reducing the severity of bipolar episodes (Joyce, 1985; Perry et al., 1999).  Moreover, psychosocial interventions that include early symptom monitoring have also been shown to positively assist in: relapse prevention, increasing time to relapse, decreasing rate of hospitalisation, lowering symptom severity and episode length, and enhancing quality of life (Gitlin et al., 1995; Lam et al., 2003; Morriss et al., 2002; Scott et al., 2001).

Patients with chronic conditions including bipolar disorders report a need for both self-help and psychosocial treatments in conjunction with pharmacotherapy (Hill, Hardy & Shepard, 1996; Lish et al., 1994), in which they are an active partner in the management of their condition. Psychosocial interventions that include early monitoring of prodromal symptoms meet this need by assisting patients to become aware of symptomatic changes in mood, cognition and behavior; to categorise these symptoms and processes with their clinicians and to use this information and skill set to develop coping strategies for prodromal symptoms (e.g. strategic and responsive lifestyle alterations, behavioral modification or seeking assistance) (Lam et al., 1999).  Research has demonstrated that patients with bipolar disorders can effectively recognise and report prodromal symptoms of a behavioral, mood and cognitive nature (Lam et al., 2001; Mantere et al., 2008) and can distinguish between both elevated and depressed symptoms (Jackson et al., 2003) – findings which lend weight to the appropriateness of this approach in treating bipolar patients in active and remission phases.

The Early Symptom Monitoring Inventory provides a simple, low time investment method for patients to report daily mood states (both high and low, and with a measure of severity) and critical preventative behaviors (sleep, exercise, medication adherence and existence of life stress). It is tailored to be a general inventory, and is therefore able to be usilied in any of the relevant therapies noted above where early monitoring of prodromal symptoms is prescribed by the treating clinician.

Why complete the Early Symptom Monitoring Inventory (ESMI)?

Early symptom monitoring and management is an important part of many collaborative psychological treatments for bipolar disorders. It has been shown to be beneficial in preventing relapse.

Bipolar symptoms fluctuate, and early recognition of their direction, their severity, their cycle and their relationship to other factors like medication levels and life stress, is essential in accurately diagnosing and successfully treating the disorder.  

Regularly completing the ESMI lets you monitor your symptoms and warning signs over time. The ESMI collates daily information of your moods, medication, sleep patterns and stressful events, and produces a chart which you and your clinician can use to monitor whether you are recovering or whether you are experiencing a worsening of symptoms which require early action to reduce the chance of relapse.  Attempting to remember this information over time can be difficult, and especially when you are unwell. Understanding this information can help you see important relationships and patterns that could otherwise be undetected.

How do I complete the ESMI?

The ESMI is conveniently contains a whole month on one sheet.  You can print it out and complete by hand, or complete the file electronically.

After entering your name and the relevant month and year, complete the form each day as follows:

• Mood: At the same time each day tick the column for that day twice – one for the highest elevation of mood, and one for the lowest dip in mood for that day. 

o If you experienced a particular symptom you believe important to record in detail, additionally enter the date and details of that symptom in the Detailed Notes sheet.

• Sleep: At the same time each day enter the length of time you slept in that day in hours. 

• Medication: 

o Medication Name: Enter the name of each of your medications at each line in the document provided.

o Daily Medication Dose Taken: At the same time each day enter in the column for that day the dose in mg of the medication you have used.

• Stressful Life Event: If you have experienced a stressful life event in a particular day, tick the box for that day, and then enter the date and details of that event in the Detailed Notes sheet.

• Exercise: At the same time each day tick the column for that day if you have exercised in a way that you believe reflects the exercise discussed in your treatment sessions.

What should I do if I notice an increase in symptom severity?

To ensure the best chances of avoiding relapse, it is important that you contact people in your designated support network and your psychologist if you notice any increase in symptom severity.

References

Castle, D., Berk, M., Berk, L., Lauder, S., Chamberlain, J. & Gilbert, M. (2007).

Pilot of group intervention for bipolar disorder. International Journal of Psychiatry in

Clinical Practice, 11 (4), 279-284.

Colom, F., Vieta, E., Reinares, M., Marinez-Aran, Torrent, C., Goikolea, J.M. &

Frank, E., Swartz, H.A. & Kupfer, D.J. (1999).  Interpersonal and Social Rhythm

therapy: managing the chaos of bipolar disorder. Biological Psychiatry, 48 (6), 593-60

Gasto, C. (2003). Psychoeducation efficacy in bipolar disorders: Beyond compliance

enhancement. Journal of Clinical Psychiatry, 64 (9), 1101- 110

Gitlin,  M.J.,  Swendsen,  J.,  Heller,  T.L.  &  Hammen,  C.  (1995).  Relapse  and

impairment in bipolar disorder. American Journal of Psychiatry. 152, 1635-1640.

Hill, R., Hardy, P. & Shepherd, G. (1996). Perspectives on manic depression: A

survey of the manic depression fellowship. London: The Sainsbury Centre  for Mental

Health.

Jackson, A., Cavanagh, J. & Scott, J. (2003). A systematic review of manic and

depressive prodromes. Journal of Affective Disorders, 74, 209-217.

Joyce, P.R.  (1985).  Illness behaviour and  rehospitalisation in bipolar affective

disorder. Psychological Medicine, 15, 521-525.

Lam, D.H., Jones, S.H., Hayward, P. & Bright, J.A.  (1999). Cognitive therapy

for bipolar disorder: A therapist's guide to concepts, methods & practice. John Wiley & Sons, Ltd. Chichester.

Lam, D.H., Bright, J., Jones, S., Hayward, P., Schuck, N., Chisholm, D. & Sham,

P.  (2000). Cognitive therapy  for bipolar illness – A pilot study of  relapse prevention.

Cognitive Therapy and Research, 24 (5), 503-520.

Lam, D.H., Watkins, E.R., Hayward, P., Bright, J., Wright, K., Kerr, N. et al.

(2003). A randomized controlled study of cognitive therapy for relapse prevention for

bipolar affective disorder. Archives of General Psychiatry, 60, 145- 15.

Lam,  D.H.,  Hayward,  P.,  Watkins,  E.R.,  Wright,  B.A.,  &  Sham,  P.  (2005).

Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after 2 years. American Journal of Psychiatry, 162 (2), 324-329.

Lish,  J.D.,  Dime-Meenan,  S.,  Whybrow,  P.C.,  Price,  R.A.,  Hirshfield,  R.M.

(1994). Bipolar Depression: The real challenge. European Neuropsychopharmacology, 14, S83-S88.

Mantere,  O.,  Suominen,  K.,  Valtonen,  H.M.,  Arvilommi,  P.  &  Isometsa,  E.

(2008).  Only  half  of  bipolar  I &  II  patients  report  prodromal  symptoms.  Journal  of Affective Disorders, 111 (2), 366-371.

Molnar, G., Feeney, G. & Fava, G. (1988). Duration and symptoms and bipolar prodromes. American Journal of Psychiatry, 145, 1576- 1577.

Morriss, R., Marshall, M. & Harris, A. (2002). Bipolar affective disorder – left out in the cold. British Medical Journal, 324(7329), 61-62.

Perry,  A.,  Tarrier,  N.,  Morriss,  R.,  McCarthy,  E.,  &  Limb,  K.  (1999). Randomised  controlled trial  of  efficacy  of teaching  patients  with  bipolar  disorder to  identify early symptoms of relapse and obtain treatment. British Medical Journal, 318, 149-153

Scott,  J.,  Stanton,  B.,  Garland,  A.,  & Moorhead,  S.  (2001).  A  pilot  study  of cognitive therapy in bipolar disorder. Psychological Medicine, 31, 459-467.

Simoneau,  T.L., Miklowitz,  D.J.,  Richards,  J.A.,  Saleem,  R.  &  George,  E.L. (1999).  Bipolar  disorder  and  family  communication:  Effects  of  a  psychoeducational treatment program. Journal of Abnormal Psychology, 108 (4), 588-597.

 

 

 

 

 

 

 

 

Social Media Election

I received a request from this interesting site to see if I'd be interested in posting this infographic on the use of social media in elections in general, and the 2012 US presidential election in particular.  Such a fascinating presentation of statistics on the changing face of how democracy is managed, deployed and fought in our information age.

Created by http://open-site.org">Open-Site.org
 
Created by http://open-site.org">Open-Site.org

http://www.thepresentparticiple.blogspot.com

Resilience in Children - Moving from Deficit to Strength-Based Models. - Luke Fullagar

Resilience in Children - Moving from Deficit to Strength-Based Models. 

Luke Fullagar

RMIT University

Developmental research has identified a range of personal and circumstantial risk factors which increase the likelihood that a child will develop social, emotional and/or behavioural problems (Keogh & Weisner, 1993).  A range of studies with at-risk and normal populations have demonstrated that increases in risk factors are associated with lessening the chance of positive outcomes (Werner, 1993). For example, Rutter, Maughan, Mortimore, Ouston and Smith (1979) found an exponential relationship between the number of risk factors and the rate of psychiatric disorders in children of mentally-ill parents, and Gilligan (2000) found that the reduction in the number of risk factors resulted in a statistically-significant enhancement in functioning.  The cumulative effect of risk factors on maladaptation has been noted in a number of studies (Deater-Deckard, Dodge, Bates, & Petit, 1998; Obradovic, Shaffer & Masten, 2011), and has lead to the development of 'risk gradient' measures (Obradovic, Shaffer & Masten, 2011) which have been used to demonstrate relationships between the magnitude of cumulative risk and increases in a range of health and behaviour outcomes (Masten & Osofsky, 2012; Obradovic, Shaffer & Masten, 2011).

Yet while a spectrum of physical and psychological events have been shown to increase risk of maladaptation and development of psychopathology, significant variability in adaptive function in children has been simultaneously observed across this spectrum (Ezpeleta, Granero, De la Osa & Guillamon, 2001; Masten, et al, 1999).  Indeed, within differing levels of risk, both high and low functioning outliers have been consistently identified (Masten, et al, 1999) such that resilient children have been shown to recover and normatively adapt and develop well beyond that expected by the range of stressors constituting their 'risk gradient', while others have coped far worse than might have been expected at lower risk-levels (Masten, et al, 1999).

The diversity of developmental outcomes for children who share high-risk factors has lead to a shift in research focus from deficit to strength-based approaches (Waller, 2001).  The research aim of this work has been to identify the personal and environmental factors that promote resilience, and to promote these factors in other at-risk children to promote more positive outcomes (APS, 2005).  

In a seminal study, Waller (2001) found that although increases in risk factors were typically associated with negative outcomes, the existence of crucial protective factors insulated against the negative effect of risk. These protective factors are defined as those personal and environmental qualities that moderate the child's vulnerability to risk-factors, including both personal assets and access to resources (APS, 2005). In addition to protective factors, promotive factors have also been implicated in resilience and are those personal resources and relationships which positively contribute to adaptation and development regardless of risk level (Masten, Monn & Supkoff, 2011). It is this relationship between risk, protective and promotive factors which has been instrumental in developing models of resilience (APS, 2005).  

Interestingly, research has shown that no one protective factor operates as a panacea, and that there are multiple pathways to resilience across a range of contexts, trauma severities and developmental levels (APS, 2005; Masten, Monn & Supkoff, 2011). Widely accepted promotive or protective factors include good caregiving, close relationships with other competent and pro-social people, intelligence and problem-solving skills, self efficacy and positive self-perceptions, hope, faith and positive self perceptions and effective schools (Masten, Monn & Supkoff, 2011).  Furthermore, the security of attachment relationships which provide emotional security, stability, physical defence, practical assistance and access to resources, have been consistently found to be critical as promotive and protective factors. Indeed, in a large longitudinal study in Hawaii, Werner (1993) found that resilient children each identified at least one person to had believed in them and offered support. 

However, while research demonstrates that both personal and circumstantial factors contribute to resilience, Kalland (2002) offers evidence that personal factors may offer the greatest impact to resilience.Indeed, Werner (1993) also found that resilient children also had at least one skill or ability that provided them with a sense of efficacy and resultant acceptance into peer groups.  Additionally, a child's capacity to control, regulate and modulate their attention, impulses and emotions has been noted as a critical personal factor in both modulating reactions to risk factors, but also in stimulating healthy socialiasation and peer acceptance (Masten, Monn & Supkoff, 2011).  

However, Masten et al's (2005) research demonstrates the synthesis of individual and social factors, noting that protective and promotive factors are located inside adaptive systems of self, attachment relations, family, community and emergency response systems of the state (Masten, Monn & Supkoff, 2011), and that lasting threats to welfare are most prominent where access to these factors is damaged, impaired or destroyed (Masten, Monn & Supkoff, 2011)

Importantly for those children who do not demonstrate adequate coping skills, Werner also found that resilience was still able to be developed through education and intervention programs which taught social skills and problem solving (Werner, 2003).  A range of intervention programs have been developed in light of this research, focusing on reducing the magnitude and number of risk factors and promoting protective and promotive factors (APS, 2005), and improving crucial adaptive systems including those incorporating parents, mentors, teachers and community systems (Masten, Monn & Supkoff, 2011)

In conclusion, while it is evident from the research that higher levels of risk factors are associated with the risk of poorer outcomes, significant research also demonstrates how certain protective factors are utilised in a range of contexts to preserve, protect, and promote recovery and adaptation during and after trauma.  Although child welfare remains at risk when risk factors are high, resilience research offers a promising beacon of hope for assisting these children achieve the healthiest adaptation and functioning possible given their circumstances.

 

References

APS, The Australian Psychological Society. (2005) The Resilient Child. InPsych. Retrieved 11 October 2012 from http://www.psychology.org.au/publications/inpsych/resilient/

Deater-Deckard, K., Dodge, K. A., Bates, J. E., & Petit, G. S. (1998). Discipline among African American and European American mothers: Links to children's externalizing behaviors. Developmental Psychology, 32, 1065–1072.

Ezpeleta, L., Granero, R, de la Osa, N, & Guillamon, J. (2001). Assessment of Functional Impairment in Spanish Children. Applied Psychology, An International Review. 55(1), 130-143.

Gilligan, R. (2000). Adversity, resilience and young people: The protective value of positive school and spare time experiences. Children and Society, 14, 37-47.

Kalland, M. (2002). Risk and protective factors affecting the development of children in foster care: Systemic approach. Paper presented at the August IFCO 2002 Conference, Tampere, Finland.

Keogh, B. K., & Weisner, T. (1993). An ecocultural perspective on risk and protective factors in children's development : Implications for learning disabilities. Learning Disabilities Research and Practice, 8, 3-10.

Masten, A, S. Hubbard, J.J. Genst, S.D, et. al. (1999). Competence in the context of adversity: Pathways to resilience and maladaptation from childhood to late adolescence. Development and Psychopathology. 11, 143-169.

Masten, A. S., & Osofsky, J. (2012). Disasters and the impact on child development: Introduction to the special section. Child Development, 81, 1029-1039.

Masten, A.S., Monn, A.R &  Supkoff, L.M. (2011) Resilience in Children and adolescents. In Southwick, S.M., Litz, B.T., Charney, D. & Friedman, M.J. (Eds). Resilience and Mental Health: Challenges Across the Lifespan. Cambridge: Cambridge University Press.

Rutter, M., Maughan, B., Mortimore, P., Ouston, J., & Smith, A. (1979). Fifteen Thousand Hours. Cambridge, MA: Harvard University Press.

Obradović, J., Shaffer, A. E., & Masten, A. S. (2012). Adversity and risk in developmental psychopathology: Progress and future directions. In L. C. Mayes & M. Lewis (Eds.), A Developmental Environment Measurement Handbook. New York, NY: Cambridge University Press.

Waller, M. A. (2001). Resilience in ecosystemic context: Evolution of the concept. American Journal of Orthopsychiatry, 71, 290-297.

Werner, E. E. (1993). Risk, resilience, and recover: Perspectives from the Kauai longitudinal study. Development and Psychopathology, 5, 503-515.

Synthesis, Play, Dreaming.

"Play marks a step forward in the evolution of communication - the crucial step in the discovery of map-territory relations. In primary process, map and territory are equated; in secondary process they can be discriminated. In play, they are both equated and discriminated"

- Gregory Bateson.

"If we speculate about the evolution of communication, it is evident that a very important stage in this evolution occurs when the organism gradually ceases to respond quite 'automatically' to the mood signs of another and becomes able to recognize the sign as a signal: that is, to recognize that the other individual's and its own signals are only signals, which can be trusted, distrusted, falsified, denied, amplified, corrected, and so forth"

... this brief digression will serve to illustrate a stage of evolution - the drama precipitated when organisms, having eaten of the fruit of the Tree of Knowledge, discover that their signals are signals. Not only the characteristically human invention of language can then follow, but also all the complexities of empathy, identification, projection, and so on. And with these comes the possibility of communicating at the multiplicity of levels of abstraction mentioned above".

- Gregory Bateson

"In my experience the ontology of the Aboriginal dreamtime is unique. It has developed on the Australian mainland for at least 50,000 years in direct response to the calls of the ice ages, flora and fauna, landforms, and peoples of this continent.  From this vantage point there is no need for concepts such as individuality, ego, possessions, nor is there separation of mind, matter and soul or Karma as they are commonly understood.  This view is not unilinear in the Western time sense, with the movement into the future being to progress through 'times arrow' from the past through present to a bigger and better tomorrow. Nor is this perspective a traditional Christian one where the manifest 'I', is in need of 'salvation' because of 'original sin' and 'fallen nature', which we seek to overcome through 'repentance' in order to become a 'chosen one' and thereby achieve 'resurrection'.  Also unlike the scientific tradition there is no separation of subject/object.  Further, it is not a circular expression, as in the cycle of the ages of the Eastern, Hindi, sense. Nor does it suggest an absorption into the cosmic whole as in the Buddhist journey, which is a sort of reversed Western story/myth leading to the absorption of the 'I'. Further, it is not mystic in the Sufi sense of seeking all one needs inwardly and taking one's roots from the phenomenal world and placing them in the Divine.  Finally it is not mystic in the Gnostic sense of direct apperception of God".

- Paul Wildman

"Virtual worlds provide a unique context for ethnographic research because they are, by definition, performative spaces. Unlike traditional ethnography, one cannot enter into an online game or virtual world without joining in the performance. There is no defined distinction between performer and audience; they are one in the same. Goffman's concept of the performance of everyday life (Goffman 1959), especially in the context of public space (Goffman 1963), provides us with a starting point for understanding network game space as a kind of "everyday" co-performance. Thus when we talk about the phenomenon of "seeing and being seen," we are also implicating the importance of both having and being an audience: the performance is only meaningful if there is someone there to see it. In more recent research, looking at real-life costume play, I've observed this phenomenon in the physical context of a fan convention. Each costumed participant took the role of both performer and audience, constantly shifting roles, and sometimes inhabiting both at once. (REF: Dragon*Con research) This co-performative framework can be seen in myriad contemporary ritual practices, from the fan conventions to Renaissance Faires to the annual Burning Man festival, all of which blur the boundaries between Turner's liminal and liminoid spaces".

- Celia Pearce

The Burning Man Zodiac:

http://theshroom.wordpress.com/burning-man-zodiac/

Free Will Astrology:

http://www.freewillastrology.com/

A Spell to Commit Pronoia

-  Jennifer Welwood:

Willing to experience aloneness,

I discover connection everywhere;

Turning to face my fear,

I meet the warrior who lives within;

Opening to my loss,

I am given unimaginable gifts;

Surrendering into emptiness,

I find fullness without end.

Each condition I flee from pursues me.

Each condition I welcome transforms me

And becomes itself transformed

Into its radiant jewel-like essence.

I bow to the one who has made it so,

Who has crafted this Master Game;

To play it is pure delight,

To honor it is true devotion.

Lean Into It - Ben Lee

Evidence-Based Treatment of Post-Traumatic Stress Disorder

Evidence-Based Treatment of Post-Traumatic Stress Disorder

  

Luke Fullagar 

RMIT University

 

 

This paper outlines the evidence base for the treatment of post-traumatic stress disorder (PTSD) in adults. Due to its Australian-context, this paper primarily relies on the meta-analysis completed by the Australian Centre for Posttraumatic Mental Health (ACPMH ) in 2007 (ACPMH, 2007), which includes and transcends the prior seminal systematic meta-analysis undertaken by United Kingdom National Institute for Clinical Excellence (NICE) in 2005 (NICE, 2005). Given word restrictions, for brevity, study references in this paper will generally refer to additional studies included in the expanded evidence-base reviewed by the ACPMH, and should be taken as extending rather than ignoring the NICE evidence base (as is the spirit of the ACPMH report).

Currently, the strongest-evidence base for psychological treatment of adults with PTSD is in respect of two trauma-focussed interventions: trauma-focussed cognitive behavioural therapy (TF-CBT) and eye movement desensitization (EMDR) and reprocessing treatment together with in vivo exposure therapy (ACPMH, 2007).  Over 30 controlled studies support these broad conclusions and demonstrate effectiveness in both PTSD symptoms and with comorbid depression and anxiety (ACPMH, 2007).  The following expands on this evidence, and concludes with a comparison of these treatments, and their recommended application in clinical settings.

Randomised controlled trials comparing TF-CBT in a range of contexts (e.g. earthquake victims, partner abuse), have demonstrated consistent, statistically-significant clinical superiority to waitlist conditions in reducing PTSD symptom severity and post-treatment diagnosis (both self-reported and clinician-rated) (ACPMH, 2007; Ehlers et al., 2005; Kubany et al., 2004; Basoglu et al., 2005; Lindauer et al., 2005; McDonagh et al., 2005; Rothbaum et al., 2005).  Moreover, two studies have demonstrated statistically-significant improvements in functioning in people receiving FT-CBT when compared with waitlist-conditions (ACPMH, 2007; Ehlers et al., 2005; Basoglu et al., 2005).  While the NICE study found significant evidence favouring FT-CBT over waitlist-conditions in reducing anxiety-related symptoms, subsequent studies reviewed by the ACPMH found a variant, and overall lesser standard of evidence (ACPMH, 2007; McDonagh, 2005; Ehlers, 2005). The NICE study found limited evidence for clinical superiority of FT-CBT over waitlist conditions for depression symptoms (NICE, 2005), and while observing a range of studies with very low or no statistically-significant reductions in depressive-symptoms, the ACPMH study noted two studies which demonstrated this relationship in populations which were predominantly woman aged in their late 30s to 40s (ACPMH, 2007; Kubany 2004; Ehlers, 2005).  Currently, evidence is unclear on the efficacy or clinical importance of FT-CBT in increasing self-reported quality of life (ACPMH, 2007; McDonagh, 2005).

Similarly, there is limited, relevant evidence supporting EDMR over waitlist-conditions in reducing PTSD symptom severity and post-treatment diagnosis (both self-reported and clinician-rated), depressive symptoms, anxiety symptoms and in increasing self-reported quality of life (NICE, 2005).

When comparing these treatments, both the NICE and ACPMH meta-analyses revealed inconclusive evidence to determine whether TF-CBT and EDMR differ in clinical importance on reducing PTSD symptom severity, post-treatment diagnosis (both self-reported and clinician-rated), clinician-rated symptom severity at 3 month follow up, anxiety symptoms at treatment conclusion and at 2-5 month follow-up, and in increasing self-reported quality of life (ACPMH, 2007; NICE, 2005).  Evidence also suggests that there is unlikely to be a clinically important difference between these treatments in respect of self-reported PSTD symptoms at 3-month follow-up, self-reported depression symptoms at 2-5 month follow-up, and limited evidence favouring EDMR over TF-CBT in reducing self-reported depression symptoms at treatment cessation (ACPMH, 2007; NICE, 2005). 

However, despite these statistical results in meta-analyses, a close inspection of the cases making up these analyses reveals qualitative differences in follow-up outcomes (ACPMH, 2007). There is support for opposing views: two studies demonstrate exposure's superiority over EDMR (which demonstrated some return to baseline at follow-up) (Devilly & Spence, 1999; Taylor, 2003) and another with regard to depression and end-state functioning at follow-up (Rothbaum, 2005); while in the converse Ironson (2002) and Lee (2002) demonstrate EDMR's superiority at follow-up.  The ACPMH (2007) argue that alterations to contemporary EDMR which include in vivo exposure and CBT techniques such as cognitive interweaving, future templating, create confounds in this comparison, and that there is therefore a case for treating contemporary EDMR as a variant of TF-CBT (ACPMH, 2007).  This view is supported by evidence suggesting that the aforementioned elements of contemporary EDMR potentially contribute more than the eye-movements themselves (Foley & spates, 1995; Renfrey & Spates, 1994), and critically, the cognitive restructuring and exposure components. 

While some evidence exists suggesting that cognitive restructuring and exposure components are efficacious on their own and demonstrate no improved outcomes when combined (Bryant, 2005; Marks, 1998), the lack of independence between these two treatment variables confounds the current evidence, and accordingly, no conclusive position is yet available on this point (ACPMH, 2007).  On this point, it is also important to note that other treatments such as psychoeducation, anxiety management and stress-inoculation training – which have demonstrated better than wait-list effectiveness yet lower than trauma-focussed treatment effectiveness in reducing post-treatment diagnosis, on follow-up and in treating comorbidities – are all included as elements in the more efficacious trauma-focussed treatments described herein (ACPMH, 2007).

No current evidence base exists for recommending a number of treatment sessions, and studies included in meta-analyses have ranged from single sessions to treatment protocols of 4-14 sessions (ACPMH, 2007).

No current evidence exists demonstrating any superiority of pharmacotherapy over trauma-focussed psychotherapeutic interventions on any of the abovementioned measures, and importantly, on dealing with depression comorbidity (NICE, 2005). Accordingly, it is recommended by NICE and ACPMH that pharmacotherapy not form a routine non-selective first-line treatment for traumatised adults in preference to trauma-focussed psychotherapy (ACPMH, 2007). However, on the basis of a Cochrane Review (Stein et al, 2006), which demonstrates that the greatest number of trials demonstrating efficacy were in respect of SSRIs, ACPMH recommends that where medication is prescribed in the treatment of PTSD in traumatised adults, SSRI antidepressants should be the first-choice.

 

References

 

ACPMH (Australian Centre for Posttraumatic Mental Health). (2007). Australian Guidelines for Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: Australian Centre for Posttraumatic Mental Health.

Basoglu, M., Salcioglu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal of Traumatic Stress, 18(1), 1–11.

Bryant, R. A., Moulds, M. L., Guthrie, R. M., & Nixon, R. D. V. (2005). The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder. Journal of Consulting and Clinical Psychology, 73(2), 334–340.

Devilly, G. J., & Spence, S. H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorders, 13(1–2), 131–157.

Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, M. (2005). Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behaviour Research and Therapy, 43(4), 413–431.

Foley, T., & Spates, C. R. (1995). Eye movement desensitiation of public-speaking anxiety: A partial dismantling. Journal of Behavior Therapy and Experimental Psychiatry, 26, 321–329.

Ironson, G., Freund, B., Strauss, J. L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58(1), 113–128.

Kubany, E. S., Hill, E. E., Owens, J. A., Iannce-Spencer, C., McCaig, M. A., Tremayne, K. J., & Williams, P. L. (2004). Cognitive Trauma Therapy for Battered Women With PTSD (CTT-BW). Journal of Consulting and Clinical Psychology, 72(1), 3–18.

Lee, C., Gavriel, H., Drummond, P., Richards, J., & Greenwald, R. (2002). Treatment of PTSD: Stress inoculation training with prolonged exposure compared to EMDR. Journal of Clinical Psychology, 58(9), 1071–1089.

Lindauer, R. J. L., Gersons, B. P. R., van Meijel, E. P. M., Blom, K., Carlier, I. V. E., Vrijlandt, I., & Olff, M. (2005). Effects of brief eclectic psychotherapy in patients with posttraumatic stress disorder: Randomized clinical trial. Journal of Traumatic Stress, 18(3), 205–212.

Marks, I., Lovell, K., Noshirvani, H., Livanou, M., & Thrasher, S. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: A controlled study. Archives of General Psychiatry, 55(4), 317–325.

McDonagh, A., Friedman, M., McHugo, G., Ford, J., Sengupta, A., Mueser, K., Demment, C. C., Fournier, D., Schnurr, P. P., & Descamps, M. (2005). Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(3), 515–524.

NICE (National Institute for Clinical Excellence) (2005). The Management of PTSD in Adults and Children in Primary and Secondary Care (Vol. 26). Wilshire: Cromwell Press Ltd.

Renfrey, G., & Spates, C. G. (1994). Eye movement desinsitization: A partial dismantling study. Journal of Behavior Therapy and Experimental Psychiatry, 25, 231–239.

Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607–616.

Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews(1).

Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K., & Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330–338.

 

35!

35 spins around that shiner,

Happier, luckier, never wiser,

35 more to make it finer,

'til I will my days from a Jason Recliner.

- Enmore, 23 September 2012.

Reflections on the Aetiology, Pathogenesis and Diagnostic Reassignment of Gambling Dysfunctions in the DSM-V

Reflections on the Etiology, Pathogenesis and Diagnostic Reassignment of Gambling Dysfunctions in the DSM-V

Luke Fullagar

RMIT University

Academic debate has not reached a universally accepted conclusion on the etiology and pathology of dysfunctionalgambling. Current theory and empirical research remains uncertain on whether dysfunctional gambling should most parsimoniously be considered a behavioral addiction, an obsessive-compulsive or a disorder of impulse control (APA, 2010).  This poses difficulties for both treatment development and diagnosis.  Moreover, contemporary research has demonstrated that dysfunctional gambling may not form one disorder arising in a homogenous population, but may instead be more accurately explained as a heterogenous group of populations differentiated in etiology, pathogenesis and severity, despite the display of similar phenomenological features (Blaszczynski & Nower, 2002). 

The history of the Diagnostic and Statistical Manual's (DSM) treatment of dysfunctional gambling highlights both the uncertiainty which has pervaded classification, and the development over time in understanding its complex of contributory factors. Based on significantly limited research (Blaszcynski, 2005; Rodda, Lubman & Latage, 2012), a diagnosis of Pathological Gambling was originally included in the DSM-III as a disorder of impulse control. Remodeling of criteria in the DSM-III-R was similarly undertaken with minimal recourse to empirical research (Blaszcynski, 2005) and based on substance abuse characterisations which included items of preoccupation, tolerance, withdrawal and efforts to minimise or eliminate gambling (APS, 2010; Rodda, Lubman & Latage, 2012). This model largely endured in the DSM-IV and is currently the dominant theoretical paradigm (Blaszczynski & Nower, 2002; National Research Council, 1999). However, a line of developing research on gambling uses for mood regulation (e.g. dissociation) and not impulse control (Anderson & Brown, 1984; Jacobs, 1986) was recognised by the addition of a new item 'gambling as a means of escape'.  Important also was Rosenthal's (1989) suggestion in the DSM-IV review process that criteria should account for the progressive nature of dysfunctional gambling, and distinguish between pathological and non-pathological variants. 

Indeed, in the 30 years since the first inclusion of gambling in the DSM, myriad course identifiers and predictive risk factors associated with dysfunctional gambling have been demonstrated, including: access, impulsivity, biological vulnerabilities, behavioural conditioning, emotional-regulation issues, family history, peer group influences and pre-existing psychopathology (Blaszczynski & Nower, 2007; Brewer, Grant, & Potenza, 2008; Toneatto & Nguyen, 2007).   In recent times, a number of multifactorial integrated biopsychosocial models have been advanced in an attempt to coherently assimilate these research findings (APS, 2010). Chief among these is the Pathways Model (Blaszczynski & Nower, 2007) which advances three subtypes differentiated on pathogenesis and increasing severity: (1) behaviourally-conditioned gamblers affected primarily by access, conditioning and cognitive processes; (2) emotionally-vulnerable gamblers for whom behavioral conditioning and erroneous cognitions are intensified by extant psychopatholgy including prior emotional and family disturbances, poor coping skills, low-self esteem, and social isolation, and for whom gambling is also a strategy for mood regulation (e.g. dissociation) and induction (e.g. arousal); and  (3) impulsive anti-social problem gamblers for whom preexisting psychopatholgy, genetic and neurochemical factors interact to intensify impulsivity and need for stimulation (Blaszczynski & Nower, 2002; APA, 2010; Blaszczynski & Nower, 2007). 

However, despite this growing evidence of a complex heterogeneous set of circumstances, it is proposed that the DSM Pathological Gambling diagnosis be reclassified as a one-dimensional behavioral addiction labeled DisorderedGambling in the DSM-V.  Some support exists for an addiction model. Clinical and epidemiological studies demonstrate high comorbidity with substance abuse (Petry, 2005). Problem gamblers also present with excessive preoccupation and urges to gamble despite negative consequences, difficulty with reduction and cessation (cf. Blaszczynski & Nower, 2002), and symptoms of withdrawal and tolerance (XXX; APA, 2010). 

However, this model has also drawn significant critique.  Substances, unlike gambling, directly reinforce cognitive and neurological processes that adapt and develop dependence. Studies observing boredom in participants engaging in moneyless simulated gambling are used as evidence that the arousal to gamble is associated with anticipated wins not the consequence of the direct act itself (Blaszczynski, 2005).  Moreover, it is argued that the chasing behaviour witnessed in dysfunctional gamblers is wrongly paralleled with dose tolerance in substance abuse, and better understood as at attempt to recoup lost money (Blaszczynski & Nower, 2002).  Furthermore, evidence that dysfunctional gambling is often motivated by a range of persistent erroneous and irrational beliefs which disregard logical probability and mutual independence of chance events despite direct and experiential evidence to the contrary (APA, 2010), is used to mount the argument that symptoms of dependence in dysfunctional gambling are of a cognitive rather than addictive nature (Blaszczynski, 2005).

In light of the above, it appears that a one-dimensional behavioral addiction model suggested for the DSM-V is unreflective of the evidence for a heterogenous condition of varying etiology, pathogenesis and severity, and accordingly a premature conclusion on the matter of dysfunctional gambling. While some arguments have been leveled that an addictions model may result in a practical increase in treatment within a professional and lay culture acquainted with the structure of addictions-modelling for other disorders (e.g. Petry, 2006; Potenza, 2006), the potential risks of unwarranted and incorrect stigmatization, slippery-slope arguments for restriction of other social freedoms, and the evidence for variant forms of gambling dysfunction lead to a conclusion that these positives are not outweighed by their disadvantages.

References

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APS Australian Psychological Society - Gambling Working Group. (2010). Special Report: The Psychology of Gambling. InPsych, 6, 1-15.

Blaszczynski, A. (2005). To formulate gambling policies on the premise that problem gambling is an addiction may be premature. Addiction, 100(9), 1230-1232.

Blaszczynski, A., & Nower, L. (2002). A pathways model of problem and pathological gambling. Addiction, 97, 487-499.

Blaszczynski, A., & Nower, L. (2007). Etiological processes. In G. Smith, D. Hodgins, & R. Williams (Eds.), Research and measurement issues in gambling studies. Elsevier: Toronto. pp.317-338.

Brewer, J. A., Grant, J. E., & Potenza, M.N. (2008). The treatment of pathological gambling. Addictive Disorders Treatment, 7, 1-13.

Jacobs, D. F. (1986). A general theory of addictions: A new theoretical model. Journal of Gambling Behavior, 2, 15-31.

National Research Council (1999). Pathological gambling: A critical review. Washington D.C.: National Academy Press.

Rodda, S. N., Lubman, D. I., & Latage, K. (2012) Problem gambling; aetiology, identification and management. Australian Family Practice, in press.

Petry, N. M. (2005). Pathological gambling: Etiology, comorbidity and treatment. Washington D.C.: American Psychological Association.

Petry, N. (2006). Should the scope of addictive behaviors be broadened to include pathological gambling? Addiction, 101, 152-160.

Potenza, M. (2007). Should addictive disorders include non-substance-related conditions? Addiction, 101,142-151

Rosenthal, R. J. (1989). Pathological gambling and problem gambling. Problems of definition and

diagnosis. In H.J. Shaffer, S. Stein, B. Gambino, and T.N. Cummings, (Eds.), Compulsive gambling: theory, research, and practice. MA, England. Lexington. pp.101-125.

Toneatto, T., & Nguyen, L. (2007). Individual Characteristics and Problem Gambling Behavior. In G.

Smith, D. Hodgins & R. Williams (Eds). Research and measurement issues in gambling studies, Sydney: Elsevier. pp. 92-103. Toneatto, T. & Gunaratne, C. (2009). Does the treatment of cognitive distortions improve clinical outcomes for problem gambling? Journal of contemporary psychotherapy, 39, 221-229.

O'Brien, C. (2011). Addiction and dependence in DSM-V. Addiction. 106(5), 866-867.