Youth Support Library

Dr Ueli Buhlman -       Emotional Issues in Therapy

Dr Birch has kindly given me a very open title.  I would like to talk to you about the treatment in our hospital for young people with Psychosomatic illnesses, but I am not a therapist,  I am in fact a paediatrician and our hospital is not a psychiatric institution. Young people that are admitted to our  hospital are usually  in some sort of pain - so my talk is might be entitled   … ‘when the stomach  hurts,  but the soul remains silent’

Although we have heard probably the most fascinating case story this morning, I would still like to give you two case histories as well.

The first one is about a young girl, aged 16.  According to her chart from the surgical department, family history and patient history have been unremarkable.  At 16, Margaret had been admitted with a history of acute abdominal pain.  The medical work up led to a diagnosis of acute appendicitis and the patient underwent an appendicectomy. The operation and post-operative care were without problems.  About three months later Margaret started to suffer abdominal symptoms again.  On several occasions she was examined and constipation seemed to be the cause of her pain now.  Never-the-less, six months after her appendicectomy, the patient underwent another surgery intervention, this time it was laparoscopy for endoscopical division of adhesions.  After the second surgical treatment, Margaret remained well for about two weeks.  Then abdominal pain re-occurred that the patient was seen repeatedly at the unit.  It became obvious that constipation was not the major problem, but the surgeons could not find any pathology, so finally Margaret was admitted to the paediatric ward.

At the age of 16 , Margaret is a good example of what can happen when a patient is referred from one department to another - in her case from adult surgeons to the paediatricians.  On referral to the hospital we run into the first problems, and that is why I have used the particular age of 16.  Because that is where, by tradition, paediatrics ends in our country.  So anybody who is around 16 years old, is sort of not a child any more and paediatricians, if they do not find anything tend to refer the patient to the internal medicine department.  They usually say that the young woman or man are now grown up.  After a while the internists are just as frustrated as the paediatricians were before, and usually the patient is referred back to the paediatricians and so on back and forth with this game between departments.

Another case history.  -       Christine is a 15 year old with an unremarkable history up to the age 14.  Then she decided to get rid of some of her extra pounds as she put it, to explain the fact that she was eating less than usual.  As the change in her appearance was evident, teachers had the school psychologists involved.  Although Christine started regular counselling and although she seemed to get better, she continued to loose weight.  Her parents, more and more worried, decided to get another therapist, and even agreed to be involved in family therapy as well.  To cut this long story short, Christine was finally admitted with a weight of 31kg with a height of 167cm.

What I wanted to show with these two examples is that there are many patients, and in particular adolescents, where it is very difficult to say where they belong.  It is also very hard to make a choice of one way or another.  Whenever we do not know which way to go in Paediatrics, we go back to the large text book on paediatrics, and that is what we did.  I would like to quote a few things from Nelson’s text-book on Paediatrics which is the widest used book for paediatrics - a short of gold book.  The 1992 edition which is now in use is a volume of nearly 2,000 pages.  However, there are only 4 paragraphs on page 57 and 1 on page 58 about psychosomatic disorders!

‘Any kind of emotional distress may be associated with any type of psychosomatic disorder in a child or adolescent.  Particular types of feeling or conflict do not produce specific kinds of psychosomatic illness.  There appear to be both innate constitutional vulnerabilities and environmental factors, neither of which are well understood that determine why one organ or system becomes dysfunctional rather than another ...’   -  I could go on, but as you can see it is of little help in dealing with the increasing number of adolescents which are being admitted to the hospital with psychosomatic problems. 

We have tried to define the basis of work with young people suffering psychosomatic symptoms and have produced the following working definition.  A trauma, which exceeds the actual capability of being worked on, or a psychological disturbance which has been in existence since earlier childhood which has found it’s somatic outcome in disease.  This is a very open definition but as you will see, it helped us to find an approach to treat people better.

In Switzerland, except in a few hospitals, including our own, there is a real gap in care for people of between 14 and 16 with not enough psychotherapeutic institutions for adolescents.    Because there is no structure to take into account the health care needs of young people, we have difficulties in education and training, not only for physicians, but also nurses and all the medical professionals.  Along with the problem goes, the difficulty of people seeing their position within the hospital, and because of the lack of tradition for adolescent medicine or adolescent health care, we face a situation of feeling that we are still living in a developing country.  Nevertheless, although there are quite a lot of obstacles, we decided to still try to work with these adolescents, and I would like to show you the three principles that we use as a base for our daily work.

1.  The first principle is that adolescence is an age during which there is much displacement of psychological problems.  This means that the psychological approach to the adolescent is always difficult.  Body changes, during puberty, and the difficulty of accepting them, can lead to a very great insecurity in the patient, and it is this link between the psycho-social changes and the psychological problems in response to puberty changes that links somatic and psychological issues so close together. 

The tendency of splitting will influence the behaviours on the ward, making the work difficult as sudden mood changes or even an attachment to particular nursing staff or another patient, may make the work more difficult. 

We react on two levels.  We work in a very structured setting, most of the time using contracts in terms of a therapy plan.  And at the same time we give them enough flexibility, and remember it is a paediatric ward not a special adolescent unit so we need to ensure that they still feel comfortable and at ease as young people in a paediatric setting.  And the second and most important thing for us is that we have a very tight schedule with frequent team meetings.

2.  Principle number two says that when the soul remains silent it is the body that speaks.  The more difficulties adolescents have in talking about psychological problems, the more they will be prone to react with their bodies.  The consequences in our work are the following.  We carefully monitor our steps on somatic evaluation.  Which means that we always think that we might reinforce the tendency to somatisation with our investigations. This translates to an approach where we really discuss step by step whether X-ray or lab work should be done at a certain point with the psychologist in the team. 

Instead of confronting the patient verbally, we use other techniques.  Techniques which could be summarised as creative therapy, like painting, sculpture and so on and we have made the experience that very often within the team discussing the therapists that does this kind of work will bring in key issues for further discussions.  We include the physiotherapist, in particular in the treatment of the patients who have anorexia nervosa, very early during the course to try to work on that somatic perspective of psychosomatic disease.

3.  Finally our third principle is that the displacement of the somatic level can be caused by different psychological disturbances.  We do not approach the classic psychosomatic disorders like the intestinal problems or others, but we try to use our way of looking into patients personal issues for all the adolescent patients who come into the ward. 

Based on such as perspective, we left the traditional patient/doctor relationship behind and replaced it with a team approach - with a psychologist, physiotherapist, nursing staff, teacher (who also acts as the person who does the creative therapy).  We have found that our team approach has already proved to be a big advantage in comparison to the traditional setting.  We carefully monitor the patient on a comprehensive level, we have very frequent team meetings and we have strict settings and flexibility for the young people.  The goal is that when the patients are discharged from the hospital they are still very much individuals but look happy and hopefully are in good shape again.

Troy Tranah - Juvenile delinquency

What is Juvenile Delinquency?  The term is not in fact medical at all, but a legal administrative term, and given it’s reference it is tied very much to an age range from 10 to 17, and so a juvenile delinquent is a child between those ages who has been found guilty of an offence.  I guess the Jamie Bulger case highlighted the fact that for the earlier age group from 10 to 14 there are issues around the individual knowing they have done something seriously wrong rather than just naughty. It is not easy to have a clear cut line between delinquents and non-delinquents.  Researches, such as Farrington in Cambridge and others, have often come up with figures such as around 80% of adolescents have committed a criminal offence, so it is a majority of the population have committed offences, but yet not all of them have been caught, so not all of them get the classification of delinquent. 

Just to give you a picture of how many people are indeed breaking the law, you can see that for the youngest age group 1,200 per 100,000 in the 10 to 13 age group have been found guilty or have been cautioned.  (I should say that these are indictable offences, that is the more serious types of offences which usually go to crown court - not the summary offences which might include the less serious offences such as motoring offences etc.)  Delinquency rate comes to a peak around the age of 17, and you can see that for the 17 to 20 age group there is a roughly equivalent rate of offender.  It drops then drastically from the early 20s onwards.  It is coming up to 17, and this is partly that someone cannot be found guilty of an offence before the age of 10, but then after the age of 20 there is really a marked decline.

Within the adolescent groups there is a clear chronic offender group.  The Farrington study that looked at adolescents in South London, found that less than a quarter of the convicted youths were responsible for half of all the crime in that particular study..  They also found that there is a continuity in those who are offending earlier which gives us the picture that those who are offending earlier are do have the worst outcome.  Of those convicted between the ages of 10 and 16, three quarters were again convicted between the 17 and 24 yrs age span and half again in the 25 to 32. 

Moving to the causes of offending, I am just going to look at two psychological theories which might explain offending, this morning. 

Reinforcement theory - which suggests that behaviour is acquired and maintained by reinforcement, so if you do something and you receive a reward reinforcement, you are likely to repeat that behaviour in the future.  If you look at the actual pattern of offending for adolescents, the vast majority is inquisitive crime - robbery, theft, burglary, so there is clearly a link there with reward.  They are rewarded for offending in that sense because they gain the financial reward, it also terminates them having no money or a desire for money to buy.  There is also a clear social reward within some of the groups of offenders, that having committed crimes they gain approval from their peers.  Of course offenders may be caught and if you are looking at a reinforcement theory you have to take that into consideration.  Typically within this sort of population, when we look at their learning history, reinforcement and punishment, there is a sort of erratic nature in the punishment that they have endured.   The punishment from parents may be inconsistent parenting or rather harsh punishment has not always been linked to what they should or should not do.  So whether they are making the links between punishment and not doing something is open to question.

Social learning theory - which suggests that learning is again involved (which would include reinforcement) and modelling within a social context - family, peers, school, etc.  An important aspect in Social Learning theory is social cognition, the way one thinks and social skills.  Social cognition is thinking, knowledge concerning other people and their behaviour, and our own behaviour in relation to other people. 

With relevance to offending this would include - 

·      Empathy - being able to empathise to the situation of others (for example when you are taking their goods).  A number of studies have indicated that juvenile delinquents have lower levels of empathy than normal samples.  Locus of control is where you see the factors that control your life, your behaviour as coming from - whether you are controlling your life or there are external factors controlling your life.  Particularly for violent offenders, they are consistently found to feel that there are outside factors that are responsible for their behaviour.  Self control, again with violent offenders, is found to be lower. 

·      Moral reasoning - a number of researchers, including Farrington, have suggested that there is a delayed development in moral reasoning consciousness in adolescent offenders. 

·      Social problem solving.  Problem solving itself is identifying that a problem exists and then to generate possible solutions and identifying which solution is most likely to succeed, and then putting that into action.  That is problems may be stemming from actually identifying that a problem exists and then generating actually appropriate solutions rather than sitting down and discussing the problem they may just strike out and hit the person they are having the problem with. 

Social skills is again linked to understanding social signals or cues, and acting appropriately in social settings.

I am now going to look at researchers who looked at Juvenile delinquents, looked at their background and history and compared them with other samples of non delinquents to see what factors the delinquent have that are over represented in the sample. 

·      The first one is social economic deprivation.  This is a collective term for income, housing, unemployment and other factors.

·      The second is anti-social parents and siblings that would include parents that would have a history of offending or alcohol or drug abuse . 

·      Poor parental supervision is not knowing where your children are for example. 

·      Harsh erratic child rearing which has come through in many many research studies.  The rearing or the forms of punishment are both harsh, over the top and erratic. That is that a child may do something wrong which is one day left and the next is severely hit for what is possibly a minor thing. 

·      Factor five is low intelligence, school failure and types of school were found to come up in research.  Low intelligence doesn’t necessarily mean all these children would have learning difficulties, but it was significantly lower than the normal sample. 

·      Impulsiveness, that would tie in with the problem solving approach - that they don’t stop to think about an issue, they are immediately going for a reward for example. 

·      The delinquents were always found to have delinquent peers, so they are within a similar group.  That’s most likely linked to school failures, so if someone is excluded from school there is a certain rejection by normal peers, and then these children form into groups what Farrington terms as delinquent peers. 

·      Irrational decision making.  There is an element of this in a lot of the delinquents.  I recently saw a young lad who was finally going to court for over 100 offences, and he must have thought that after committing 50 offences and not being apprehended, that it made sense to commit another one.  And the money he gained from the first 50 must have been very rewarding.

So Farrington took the risk factors and put them together for his theory for offending.  Which includes  -

·      Factors which might be seen as coming from the child - impulsivity, hyperactivity, desire for reward or sensations, tendency to take risks, which then collaborates with these other things such as a poor ability to grasp abstract concepts which would include empathy that came up as a risk factor, a low IQ and that goes through to the school failure.    

·      Then we have the ego-eccentricity and selfishness which Farrington suggests may come from the parenting and separations, many separations which the child may have experienced.   Again similarly weak conscience or remorse.  These may be picked up in the social learning process, picked up similarly to the one before, modelled from peers or from parents, if the parents have been consistently offending. 

·      And motivating factors, desire for material goods.  If the adolescent has left school at 16, after basically failing at school, his ability to get a good job and gain the money he wishes to buy good clothes, cars etc is very limited, so one option is to offend.

Looking at treatment approaches.  There isn’t and never should be a consistent treatment approach for juvenile delinquents.  Everyone comes with different sets of issues, problems, history and background.  The tendency is to look at the individual and see what the actual difficulties they are presenting, such as anger, social skills, problems for may be a sex offender, problem solving for someone who is stealing money to buy drugs, and not to ignore the emotional needs that the person may have, separations, bereavements - everything which is going on for normal adolescents is going on for these too.  Basically, research would suggest that conference behavioural therapy and perhaps family focus therapy for the younger offenders is the preferred choice.  Positive outcome is most likely if the therapy, what ever it is, is focused.  There is a behavioural element and development within it.  The practitioners and whoever else is involved are properly skilled and it is community based.


Teenage Suicide - A challenge to common ideas

Patrick Alvin

Whether carried out, attempted or merely considered, suicide is a highly sensitive, controversial. and stigmatising issue.  Even today, suicides and suicidal behaviours, when they are not denied or disguised as accidents, often remain family secrets.  The violence and apparent irrationality of suicidal behaviours may trigger powerful defensive interpretations, and there is some confusion as to the respective roles of individual mental status versus family and other environmental factors.

On the whole, we professionals have not been well prepared for the subject (Alvin P, 1992).  We often avoid the work ‘suicide’ because it is distasteful; and we speak of committing suicide, as one ‘commits’ crimes, incest and the like.  This is quite ironic, because suicidal young people are themselves often victims of abusive environments, and a proportion of suicidal girls actually have a history of incest.

In the most recent survey of the French high-school population, conducted three years ago (Choquet M, 1994), suicidal thoughts had concerned a quarter of all teenagers.  Eight percent of girls and 5% of boys reported a history of suicide attempt.

There are many commonly held ideas about teenage suicide.  Most derive from over-generalisation or over-simplification, and it is my purpose to briefly question a few of them.

1 Is Adolescent suicide a clear-cut and visible clinical entity?  It is restricted to adolescents having completed or attempted suicide?

The domain of suicide covers a very broad spectrum of behaviours and emotional states.  Only visible are the correctly diagnosed suicides and the small fraction of attempted suicides registered through hospital admissions.  Below the visibility line is a much larger area where we find all other suicides, attempted suicides or self-harm, behaviours, suicidal threats, suicidal thoughts and related depressive states.  Finally, a whole set of unaccountable ‘self-sabotage’ behaviours, best described as suicide equivalents, must be included in the general picture.  These situations, which often appear as paradoxical ways to ‘survive’, may include overt suicide behaviours as well.

In other words, the domain of suicide should rather be seen as a probability risk area, and suicide vulnerable adolescents as moving in and out of suicidal risk, as their mood and life circumstances fluctuate.  Many remain unknown or unacknowledged, and of all who enter the risk area, a few will indeed finally kill themselves.

2  Are adolescent suicide attempts just one expression of the ‘adolescent crisis’?  Do they result from pressures caused by social or family violence?

It is true that suicide behaviours often follow a painful or stressful event, and that some are a genuine and critical ‘cry for help’ directly destined to the family.  But common adolescent stresses or circumstantial motives like fights with parents about parties, boyfriends and the like are nothing but triggering factors, in no way enough to ‘explain’ such acting out behaviour.  Failures, conflicts and separations are part of any normal life.

A now well-known factor for behavioural and suicidal risk among adolescents is prior physical or sexual abuse.  School drop-out is another example.  Suicidal adolescents actually often come from families that show overt or covert discord; they are surrounded by a poorly supportive or scapegoating environment and some have known previous social or foster care interventions.  But environmental problems cannot either be an explanation alone.  We all know adolescents having grown up in dramatically dysfunctional families without ever attempting suicide.

What is really in question is the adolescent’s hopelessness when confronted to all these situations, and not being able to find any issue to suffering, other than suicide (Ladame F, 1994).  Suicidal adolescents defy all stereotypes in terms of psychological make-up.  Yet they obviously tend to share a common profile or psychic vulnerability, characterised by narcissistic fragility, difficulty in controlling impulses, intolerance to loss and excessive dependence on parental ties (Jeammet, 1994).

In fact, teenage suicide always involves the synergistic intersection between external factors, which derive from biographical events and various environmental stresses, and internal factors of vulnerability, which have to do with the given personality.  Each of these sets of factors should be analysed separately.

3  Is suicide insane?  Does adolescent suicide mean overt psychiatric illness?

This is quite a touchy subject.  Most teenagers who have attempted suicide would claim that they are not crazy.  Besides, the majority is not necessarily thinking about death per se, but much rather about their living situation being intolerable.

The question of mental illness in adolescent suicide behaviours has always generated endless and sometimes confusing debates (Ladame F, 1995).  Historically speaking, suicide has always evoked ‘insanity’.  Among adults who complete suicide, a strong relationship with psychiatric illness has been found, and according to psychological autopsy studies, the same could be true for adolescents.  Besides, suicidal adolescents are often depressed or may have personality disorders.

But trying to attach adolescent suicidal behaviours as a whole to the known psychiatric entities has always been a failure, leave aside the fact that the term ‘psychiatric or mental illness’ may evoke different meanings, particularly at that age.  The truth is that the problem of suicide is not dependent on a specific illness or mental state, and cuts across all diagnostic categories.  The best we can probably say is that suicidal adolescents usually experience great pressure, isolation, and mental suffering, but that the psycho-pathology of many of them does not meet the definition of what we commonly call a ‘psychiatric illness’.  On a practical level and in our experience, only a few are deeply depressed, psychotic or remain acutely suicidal, and less than 5% of our patients require transfer to an in-patient psychiatric family (Alvin P, 1992).

4  Is the ‘seriousness’ of a suicide attempt directly related to its medical severity?

It is often heard that the lack of a true wish to die is not really suicide, but rather ‘suicidal gesture’.  It is clear that the lethality and especially the severity of intent of suicidal acts are of great importance, given their known ‘predictive’ value for repeated self-inflicted injuries or subsequent fatal outcome.  But with adolescents, the line of intention is particularly difficult to draw.  Moreover, every suicide attempt has its own degree of ambivalence and impulsivity, and the severity may depend on circumstantial factors like the nature of the home pharmacy’s supplies or even sometimes the mere availability of a loaded gun.  In other words, beyond the immediate life and death issue, the overall distinction between major and minor, ‘serious’ and ‘not serious’ suicide attempts is inappropriate and dangerous.  Assuming that only significant or major attempts are worthy of serious attention is irresponsible, because a minor gesture may very well reveal a terrible life situation or concealed personal drama.

5  Does a missed suicide have its own dissuasive effect for later repetition?  Does it only exceptionally progress to completed suicide?

Self-poisoning, a preferred female method, accounts for relatively few adolescent deaths in our countries, where there are plenty emergency care resources.  This, and the much higher proportion of suicide attempts versus suicides in adolescence could comfort the idea that only a minority of adolescents who attempt suicide progress to completed suicide.  However, in one Finnish follow-up study, the global annual risk of dying from suicide or violent death was 20 times higher among adolescent suicide attempters (Kotila 1992).  So the so-called ‘cathartic’, or ‘self-therapeutic’ effect of suicide attempts is a dangerous concept.  The estimated risk for a repeated adolescent suicide attempt approaches  40%, with the period of greater risk being the few months following the first attempt.  But most importantly, and again beyond the life and death issue, suicide behaviours during adolescence are always symptomatic of a more or less dramatic risk for later developmental harm (Granboulan 1995). 

Of course, prevention should aim at reducing repetitions.  However, the rationale of what we call tertiary prevention of suicidal behaviour, and suicide repetition is nothing but one possible event within a broader dysfunctional context, the evolution of which depends largely on what may or may not change after a suicide attempt.  In other words, preventive efforts only make sense if they stem from a thorough analysis of the given situation of a given person, and address first the various and usually long-standing factors of vulnerability, interpersonal difficulties and other dysfunctional areas brought to light by the suicidal crisis.

I will now briefly discuss intervention and prevention.   In terms of care of the hospitalised suicidal adolescent, the best time for working with the situation is the immediate time following care in the emergency room.  The suicidal crisis is best ‘exploited’ during this privileged period, which promises optimal mobilisation of the adolescent, and even more importantly, of their family (Alvin P, 1992).

There is of course not one single and ideal model of care.  But any active intervention should incorporate a set of concomitant goals at the outset:  The co-operation of the patient and his family for the understanding and management of the suicidal crisis, a complete medical and psycho-social health screening including interviews with the parents, and an appropriate treatment and follow-up plan.   This cannot reasonably be done through a single and stressful post-emergency room evaluation and besides, these patients’ well known poor compliance  with appointments after emergency care (Litt I 1983) is an argument against the idea of exclusive out-patients management at the outset.

Working with these patients ideally requires a few days of observation in a protective, transitional and non-stigmatising medical environment, with a staff emotionally prepared and well equipped for multidisciplinary work with adolescents and their families.

On a practical level, adult psychiatric wards are not usually suited for teenagers.  The best environment appears to be general medical, behavioural or psychiatric adolescent units, or structures specifically devoted to the care of suicidal adolescents.  But most hospitals do not have such units.  And the possibilities offered by Hospital child psychiatry are also limited for teenagers, especially in terms of emergency care.

In our country, general paediatric wards - with or without specified adolescent beds - have become more and more actively involved in the care of suicidal adolescents.  A recent national survey in general hospitals (Gasquet I, 1994) indicates that more than 40% of these patients are admitted to paediatric services, which provide a fairly factorable milieu for them: Compared to other wards, they offer suicidal adolescents a longer stay, an often multidisciplinary team approach, and a better follow-up with a more frequent post-discharge liaison with the family doctor.

In our experience (Alvin P, 1992), follow-up should not be planned as relying solely on psychiatric consultations.  It should be anticipated that many patients may initially refuse engaging in psychotherapy, while better accepting a general medical or social work follow-up.  This stresses the importance of a good experience in networking.  The weight or the influence of external reality may be quite important in these situations, and the therapeutic possibilities of psychiatrists or psychologists will often depend upon the presence and the quality of a parallel supportive medical and social follow-up.

In terms of suicide prevention, numerous studies have consistently identified factors found in significantly greater frequency among adolescent suicide attempters (some are family and environmental factors such as suicide or mental health problems in the family, separation or divorce, history of abuse, etc.  Others are personal behavioural or symptomatic factors such as alcohol and drug abuse, school problems, running away, depression, frequent physical complaints etc.).  The problem however is that in clinical practice, the lack of specificity and the poor predictive value of these so-called ‘risk factors’ may be quite discouraging.  The same is true for warning clues such as a recent drop in school performances.  However, we should always keep in mind that the best single predictor for suicide behaviour is a history of past suicide attempt. 

We all know that a morally distressed adolescent only waits for his suffering to be acknowledged.  But troubled adolescents often avoid whatever may evoke psychiatric services.  Moreover, they usually don’t quite know what to expect from health professionals in general, nor what they may be ready to accept from them.  Suicidal adolescents will rarely spontaneously declare : ‘I think about suicide’.  Instead, they will display various unusual physical symptoms or behaviours.

Ideally speaking, prevention should rely on every significant party or primary health care provider close to or prone to meet adolescents (Pommereau X, 1996).  One condition, however, is for these persons to be able first to establish a good enough rapport with a troubled and possibly suicidal adolescent, and second, to know how, and to whom, they should guide this young person for more specific help, in case of suicidal threat or other serious needs.   Epidemiological studies among adolescents now routinely ask about suicide on their questionnaires, without any particular back thought.  But in clinical practice, the situation appears quite different, and most professionals still experience great fear or embarrassment at the idea of addressing such questions with adolescents (Slap GB, 1996 - Capelli M, 1995).  Yet it is quite clear that raising the question of possible suicidal thoughts or past suicide attempt in the context of a thoughtful clinical interview is in no way intrusive or dangerous.  On the contrary, it provides a privileged opportunity to talk more openly about ‘what may be going wrong’.  Teenagers who feel they are not concerned will simply say no, while hearing that it is acceptable to talk about such things.

I will conclude with three simple messages, particularly for primary health care providers:-

1  Any adolescent who seems sad, anxious, depressed or who displays deviant behaviours should be asked directly the possibility of feeling like dying or of a past suicide attempt.  Prescribing anti-depressants or tranquillisers should be avoided as much as possible.  What is really needed is talking about the problems and counselling;

2  Theoretically, all adolescent suicide attempters should be sent to hospital, and remain at hospital for a few days, for a sound evaluation.  Trying to avoid drama can only add to the real drama in the long-run.

3  Primary care health providers’ role after hospitalisation is crucial, in that they can check that follow-up is effective, and that problems have not been set aside, if not simply ‘pulled down the drain’.


“Helen - A History”    Carol Kremer

- {Carol was due to present this story at the conference and was prevented from doing so by illness - however we felt it should be included in the proceedings.}

What happens to a young person who falls victim to a major mental illness? Helen was just fourteen when she began behaving in ways that were out of character: she became withdrawn and retreated to her room. To her parents she seemed traumatised, although nothing had happened to explain the frightened look that she now wore. They went, all three, to the GP who fastened on the idea of food deficiency and recommended vitamins and iron.

When Helen swung into the hypomanic phase (although no one at that stage recognised manic depressive symptoms) her parents consulted a private psychiatrist. They knew, despite the fact that Helen’s behaviour had by that time involved the police, that their daughter was ill. The psychiatrist talked about a shock syndrome.

So did the doctors in the adolescent unit of the mental hospital where Helen was next sent, and where she was held for five months while her condition was assessed.For four of those months she was denied any home visits, and she was sedated daily with major tranquillisers. Her parents watched helplessly as her physical health deteriorated. Still, they thought, she is ill and doctors and hospitals are where you turn when illness strikes.

They lost faith finally after Helen had been transferred to an adult ward on the grounds that her behaviour was unmanageable, where she was eventually Sectioned. So deep was her distress that she had not only run away but cut her wrist and cheek. The authorities’ response was to lock her up on a secure ward. Any trust that her parents had placed in the system had long gone - they wanted Helen home.

She was now on Lithium - but because her blood levels fluctuated she was accused of not taking it, and her parents were disbelieved when they confirmed she was complying with the medication as prescribed. She spent further time in hospital being monitored. Hopes of a family holiday in Italy were dashed; her brother and father went alone, she and her mother later in the year when she was finally discharged from hospital.

She is now over sixteen years old and almost entirely dependent on her family. Two punishing years have left her isolated from people of her own age, although she attends college for a day and a half each week despite suffering panic attacks and difficulties with concentration. She also attends three sessions a week at a day centre, but the people she meets there are no solution to her feelings of isolation. Her mother is her closest companion, her confidante, and Helen’s needs have to be met within the family whatever stresses may be created by that.

Helen’s family meet stress with strength and face the future without self-pity, but is this the best that can be done for young people and their families? Does treatment have to be so punitive? And do families have to cope with so little support? The mentally ill are always vulnerable - a young person’s life is especially so. Nowhere in the system is there any real provision for people like Helen, no attempt to assess the special suffering experienced by them and their families.

Perhaps there are countries where these things are handled differently, where there is something on offer at weekends for instance, where parents are not expected to assist the recovery and repair of their damaged children utterly unaided. If so, we must learn from them fast before there are too many other Helens with a story like this to tell.