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Interviewer: Hello. Welcome to the In Conversation podcast series for The Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing child and adolescent psychiatrist, Dr. Trudie Roussow, consultant psychiatrist at The Priory Hospital in North London. Trudy is also an honorary senior lecturer at University College London and clinic director at Stepping Stones Clinic.
Hi Trudie, welcome. Thanks for joining me. Can you start with an introduction about who you are and what you do?
Dr. Trudie Roussow: Okay, certainly. Thank you for having me here today. So, I’m a consultant child and adolescent psychiatrist, which means that I work with families, children and young people. People come to me for help because they worried about themselves or their child and I think people who do that, who come for help are really brave and I respect them for that. I’m a parent, myself and I know how helpless one can feel as a parent when you’re worried about your child. So, I have a great admiration and understanding for people. My philosophy is that there’s a lot of resilience and strength in people. My role is more to enable people to recover and to have mastery, themselves.
Interviewer: And how did you come to be interested in this line of work?
Dr. Trudie Roussow: Well, I studied medicine, as you do when you become a psychiatrist and, in my third year of medicine, I saw a psychiatrist through a one-way mirror sitting on the floor, working with a sad three year old and it really, really moved me. I thought, ‘wow, that’s what I want to do one day.’
Interviewer: Together with colleagues, you’ve developed an adolescent version of mentalization based treatment MBT, which is often used to help patients with borderline personality disorder. How does the adolescent version differ from MBT for adults?
Dr. Trudie Roussow: It’s a lot of overlap between the two but working with adolescents, one has to bear in mind the adolescent phase of development, which is different from where adults are at. So, young people’s brains are also different. They are far more, far more aware of the social world than adults and even, younger children. They are far more emotionally influenced by the opinion of their peers than anybody else. Emotionally, they are very reactive. I’m talking about the brain and also, a further example of brain studies is that adolescents are incredibly sensitive to the emotional environment around them. So, they have emotional reactions sometimes because somebody next to them has an emotional reaction. It is a degree of heightened sensitivity that we work with. The adolescent phase is a phase that is more vulnerable for mentalization to break down but it is also a phase where there is quite a lot of plasticity because of brain changes. So, it’s a massive period of opportunity for improvement and it’s like a window of opportunity to actually make a difference.
Also, other things that’s different in working with adolescents is the work with families, which you don’t do with the adults. Liaison with schools and social services, which you don’t do in work with adults and I see a lot of young people in what I call developmental arrest. They’ve arrested in their phase of development. They’re stuck in their bedrooms. They find it terrifying to leave the room. They’re disconnected from their friends. They don’t go to school. That’s what I call developmental arrest and some of our work really is to create a bit of a scaffolding that can hold them up and help them back into the real world whilst the therapy goes on.
Interviewer: What does the research show in terms of its success rate?
Dr. Trudie Roussow: It’s very successful in young people. I mean, the study that we did showed significant improvement in self-harm risk, depression, borderline traits, over treatment as usual. So, it’s really successful. It’s also very palatable for people. It’s not a type of therapy where people feel stressed by the therapy. It’s pleasant and I like that idea.
Interviewer: You mentioned it’s very successful with young people with self-harm and I’m aware you’ve conducted a randomized controlled trial specifically looking at its use with young people presenting with self-harm. What makes this method so relevant for that particular patient group?
Dr. Trudie Roussow: I mean we decided to do this study and I decided to use MBT for adolescents with self-harm because of the phenomenal research evidence with the adult population and how it reduced self-harm in the adult population. So, then we modified the model to use in adolescents. The philosophy behind self-harm is that young people harm themselves because of an inability to mentalise.
Now, what that means, in simple terms. When one is overwhelmed with feelings, you sometimes end up just seeing that and you don’t see somebody else’s point of view. Our minds can be, in those situations, our worst enemies because our minds can come up with all sorts of assumptions about the mind of someone else and we can arrive at some conclusion that is not actually necessarily real. But it creates a massive, big emotional impact on us. That can escalate one down into a spiral where, what I see in young people, they start to become overwhelmed with intense feelings of anxiety, self-hatred, feeling everybody else hates them, feeling they are nothing good about them. That state of mind is unbearable and then, self-harm is a way out of that state of mind. So,if one can help people to not lose the ability to mentalise, one would protect them from losing that that ability when they get emotionally overwhelmed. They’ll be able to rein back their emotions, perceive the other person and the other person’s mind in an accurate way, which will down regulate their emotions. And hence, they won’t arrive in this state that they are the worst person on Earth.
Interviewer: I understand some young people view self-harming as a coping skill or see it as a kind of release valve. How do you explain the function of self-harm?
Dr. Trudie Roussow: It is that. It helps them to cope and young people are very clear about that. Very, very, very clear about that. Exactly why, there is a whole lot of theories of why it works. I mean, one theory is that you change something that’s a mental anguish into a physical pain, that you can then do something about. You can put a plaster on, you can stop the blood, you can see the blood. It transforms what’s mental into physical.
Interviewer: It becomes more tangible.
Dr. Trudie Roussow: That’s right. There’s other theories that it has to do with endorphin release. I was very, very junior as a psychiatrist where this was brought home for me. I saw a young mum who doesn’t have a history. I don’t even think she has an awareness of self-harm and she had postnatal depression and was really struggling with her baby. One day, she was so overwhelmed. She couldn’t cope with her feelings at all, and she bashed her head against the wall and she said to me, that was fantastic. I felt so better after that. Now I know what to do when I feel like that. I mean, obviously it’s not a solution but that is a very, very clear description for the function that it serves for people and they don’t know why it works.
Interviewer: Does that make it tricky though? If it’s actually perceived to be a coping skill.
Dr. Trudie Roussow: Oh, it absolutely has a positive connotation for young people. They feel very helped by it but it creates a lot of other problems. With it, young people feel a big sense of shame. It creates a big anxiety in those around the young person. They feel those things, they need to hide from other people because, contrary to the myth that people do this for attention, it’s actually not true. Many people are deeply embarrassed about the self-harm wounds and it’s usually difficult when it’s summer and people have to start showing arms and so on. It creates a lot of shame in people. So actually, although it helps in the moment, young people would be clear, this is not something that they want to carry on with.
Interviewer: Is mentalization based treatment also useful for young people with suicidal ideation?
Dr. Trudie Roussow: Oh, yeah. I mean, it’s the same thing. A lot of these kids who harm themselves would say they feel suicidal feelings as well and they’re very clear in distinguishing. The self-harm is not an attempt to kill themselves. It’s an attempt not to kill themselves, sometimes people would say but the technique would be the same. I mean obviously, one needs to make a very clear crisis plan with young people and with parents in order to keep them safe. That crisis plan needs to be updated as the treatment goes on. Sometimes, if there’s a very, very high risk with some young people, I have asked parents that the young person sleep in their bedroom on the floor or that they sleep in the young person’s bedroom just to have more of a 24-hour vigilance. But if the young person is little bit better, then you change that and then, that’s no longer necessary.
Interviewer: How does a young person get access to this treatment? Is it widely offered or is there a greater need for and a greater dissemination and training, specifically of MBT, for adolescents?
Dr. Trudie Roussow: I mean we run two training courses for MBT, twice a year in London, and it’s always full. I think the day they open the training course, it’s booked out, almost and we run training courses all over the world. So, it’s really taking off quite a lot. But I think there is still a scarcity in services. So, yes. I think it is something that wouldn’t be available in all services. So, in terms of how would people access it, if people use their local NHS services they can only access what’s available locally, which would be the local CAMH service. Some CAMH services will have a pathway that can deliver this but I think increasingly, probably less and less services will do that because increasingly, there’s more a push for shorter sessions. There’s massive cuts. Services are completely overwhelmed. I started my private clinic, Stepping Stone Clinic to address this problem.
In my private practice at The Priory, I saw case after case, after case of young people coming from all over London, Essex, Hertfordshire, south of London, Kent, all over the place. Everybody tells the same story. Their child is self-harming and they’re on a six-month waiting list. So, I started my private clinic, that we can be responsive and deliver services to people within a week and we do various levels of intensity of MBT at the clinic.
Interviewer: Trudie, my understanding is that the evidence shows that self-harm in adolescence is increasing. Can you elaborate?
Dr. Trudie Roussow: I think it is increasing. I also see self-harm, younger and younger. I see self-harm now, sometimes in kids, ten. I’ve seen it in seven year olds. So, it’s creeping in in younger age groups. I think life today is very stressful. I think we still don’t have any idea of the stresses of the whole online world and social media. You know, in the old days kids could go home and close the door and be safe from bullies at school. Nowadays, you’re in your bed and it gets you through your phone. So, there’s a lot of that. The texture of society, also. Parents are busy. We don’t have so much external families involved in the raising of children, anymore. It’s a pressurizing world we live in.
Interviewer: Children and young people are obviously the ones who’ve been identified as having a need. How good are professionals, and I’m thinking of professionals both in health and education, in recognising and identifying those children and young people who need support?
Dr. Trudie Roussow: I think that’s getting better. I think schools are far better at picking it up. Schools are far better at making referrals when they need to. GP’s are also very good at making referrals when they need to. So, I think that is probably one of the reasons for the increase. I think it is being spoken about more. Young people are more likely to mention it to a best friend or a friend or young people are more likely to have a friend who has had something similar and who’s getting help. So, I think that is definitely more out there. Whereas, in the past, that stuff might have been hidden and secretive but I think they still have a lot of self-harm that goes under the radar.
Interviewer: And what you think the barriers are, then, that prevent young people from getting the support they need?
Dr. Trudie Roussow: I think not knowing that support is there, not feeling they can trust somebody to talk to them. I think the degree of shame that people feel might keep them quiet and silent. Young people are sometimes scared of what their parents will do if they speak up and I think the myths around self-harm are still there. The myths of he’s only doing that for attention and not actually taking it seriously, for what it is because every self-harm needs to be seen as something that needs to be helped.
Interviewer: You talked about a window of opportunity for help. How early is it necessary to get intervention?
Dr. Trudie Roussow: I think, as early as possible. It’s not just the self-harm that’s the issue here but it’s the whole mindset that goes with that. The experience of that negative spiral for a young person is an experience of, I hate myself. I am bad. If one leaves somebody exposed to that experience too long, that becomes a fact and if you leave that too long, it becomes integrated into their identities. So, you see, you really want to intervene early so that one can stop that spiral, so that they can have a different experience of themselves and build up a different identity. I mean, the whole adolescent phase is about identity and one doesn’t want that dark identity to become that’s who I am.
Interviewer: If they’re missed for some reason, what is the trajectory, really, if you have that feeling about yourself as you go into adulthood, if you’re not helped? What are your life chances?
Dr. Trudie Roussow: I mean, I think if it continues to undermine your sense of resilience, your sense of managing your life and your relationships, your sense of feeling okay in a world that sometimes is not friendly but feeling you can bounce back. So, if one of those negative feelings, it’s more difficult to have that bounce back sense and belief that one has. As a parent, you might not necessarily then, instil that in your children. That sense of confidence, that yes, things can be painful, but we can recover and we can bounce back and yes, we can get things wrong in relationships, but we can repair it and we can get back together again. Looking at the outcome studies, but this is now more focusing on borderline than self-harm, itself. The borderline studies, they’ve done a huge big study in Ameria. It’s a cohort study, so they followed children from birth up to the age of 33 and of that group was a group of children that met the criteria for borderline personality disorder in their adolescent years. Then, they looked at how did that symptomatology stay stable through the adolescent years and it stayed relatively stable throughout the adolescent years.
But the interesting thing is that group 33, at the age of 33, a lot of them didn’t meet the criteria anymore, for borderline personality disorder. This is a group of kids that don’t necessarily get any treatment because it’s just a cohort study. It’s not a treatment study, so they didn’t meet the criteria for the diagnosis anymore, at the age of 33 but, compared to their other counterparts in the study who did not have the BPD traits in adolescents, they functioned much worse in terms of economic attainment and social functioning. So, their level of functioning was lower than the other group, although they maybe, did not self-harm any more, did not have borderline traits. So, I think if you intervene early, you can change that trajectory.
Interviewer: You talked earlier about some of the issues around resources and I’m wondering what you would like to see or what policy changes are necessary to ensure that people get that?
Dr. Trudie Roussow: Well, I think a greater investment in child and adolescent mental health services, and I would think a ring-fenced investment because if an investment is in child and adolescent mental health services, and it’s not ring-fenced, we know what happens with that. Some of it gets to child and adolescent mental health services and some just simply doesn’t.
Interviewer: Trudie, you work collaboratively with families to create treatment programs. Why is this whole family approach important?
Dr. Trudie Roussow: I think it is because the child is in the family all the time and it’s no point helping one person and not support and help everybody else. I mean, it is a matter of we’re all working on this together. Everybody has a role to play. It’s not just a matter of a child that needs to be taken out and put back when the child is a different shape. It’s a matter of everybody working together and everybody benefiting from it, really.
Close: This podcast was brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short.