Australasian Psychiatry

To briefly outline historical development, theoretical orientation, evidence and areas of application for Conversational Model Psychotherapy.

Conversational Model Therapy remains an important evidence-based option in fostering recovery and growth for many patients with traumatic disruptions and restrictions of self. It is one of an emerging group of relational psychotherapies, broadly reflecting a change from a one person to a two person (intersubjective) psychological paradigm in psychotherapy.

First, to outline the paradigm change of the past 20 years that has transformed the theory and practice of child and adolescent psychodynamic psychotherapy; second, to update aspects of the current Practice Parameters for Psychodynamic Psychotherapy with Children to align with the paradigm change driven by the principles of regulation theory, relational trauma and repair, and the critical need for clinicians’ self-care in trauma informed psychotherapy.

The emerging neuroscience-driven paradigm of psychotherapy poses challenges for the child and adolescent psychotherapist: to embrace the new conceptual reference points as organising principles leads to an urgent need to rethink traditional diagnostic formulations and time-honoured techniques for intervention. Our child patients and their families are entitled to benefit from the translation of the new research evidence from attachment regulation theory to clinical psychotherapy. Our clinical psychotherapy should sustain the ‘best-interest-of-the-child’ standards for well-being while also heeding Frances Tustin’s warning for therapists to avoid the ‘perpetuation of an error’ by overlooking recent developments from allied fields in developmental psychology and the neurosciences.

This article aims to provide a brief overview of the current evidence for psychotherapeutic approaches in older adults, together with clinical practice notes for interventions.

There are a range of appropriate psychotherapeutic options for the older adult that merit further study, and further opportunities for enhancing clinical practice.

This paper describes the role forensic psychotherapy has in the assessment and treatment of mentally disordered offender patients, and its role in the supervision of individual therapists, staff groups or whole organisations which contain and manage this patient population.

Forensic psychotherapy has a valuable role to play in the management of mentally disordered forensic patients. As forensic services continue to develop in Australia and New Zealand and interest in this field continues to grow, then the future of forensic psychotherapy looks bright.

The objectives of this study were to describe advances in neurosciences and their relationship to psychodynamic models of psychopathology and to present an integrative approach to psychodynamic formulation which incorporates the neurobiological underpinnings of self-functioning and a model of relational trauma.

Developmental psychopathology is now better able to describe the significance of early developmental periods and the interpersonal context of self-development. These findings contribute to an integrated biopsychosocial psychodynamic formulation based on core principles of early development.

This article discusses Transference-Focused Psychotherapy, a contemporary evidence-based and manualised form of psychoanalytic psychotherapy for borderline personality disorder. Transference focused psychotherapy has evolved from decades of research in the object-relations approach developed by Professor Otto Kernberg and his collaborators. It is being adopted increasingly throughout North and South America and Europe, and this article explores the role its adoption might play in psychiatric training as well as public and private service provision contexts in Australia.

Transference focused psychotherapy is readily applicable in a range of training, research and public and private service provision contexts in Australia. A numbers of aspects of current Australian psychiatric training and practice, such as the Royal Australian and New Zealand College of Psychiatrists advanced training certificate, and the Australian medicare schedule, make it especially relevant for this purpose.

The objective of this study was to describe the method and relevance of infant observation as a unique and powerful learning tool for psychiatrists.

Infant observation provides a privileged entry into an infant’s internal world to observe its earliest mental life. Weekly consecutive observations of the mother–baby dyad, combined with the process of supervision, enable identification of emergent and changing patterns in the relationship. The discipline of observation encourages attunement to the nuances of relationships, which provides a potent tool for application in other clinical settings.

The aim of this paper is to explore the diversity and progress in psychoanalysis and psychotherapy post-Sigmund Freud from the perspective of Western art. Since 1900 the shift from one-person psychology to the more contemporary two-person psychology is reflected in the creativity of artists, particularly in their depiction of the mother–infant relationship.

An alternative perspective in understanding the evolution of Man’s nature can be drawn from a discourse between art, history and psychoanalytic thought. Using art as evidence that reflects concurrent changes in psychoanalytic thought is a stimulating way to engage trainee psychiatrists and psychiatrists in their exploration of human nature.

To explain the illusory nature of the self and explore its implications for psychotherapy.

Our usual experience of the self is an illusion. Rather than a discrete entity, it is a network of processes that maintains apparent irreducible unity via alterations of perceptions, beliefs, intentions and memories. By providing an efficient summary of an individual and its surroundings, the self-illusion allows one to predict, experience and interact with the world efficiently. Targeting mechanisms that preserve the self-illusion could provide a focus for psychotherapy. Viewing the self as a complex network offers a valuable conceptual framework for psychotherapy.

Few people who use stimulants seek clinical treatment. This study sought to describe a cohort of stimulant users who attended a stimulant-specific treatment service, Access Point, in Melbourne, Australia between 2008 and 2014.

A retrospective audit of the records of adults (n = 175) who sought treatment for stimulant use at a stimulant-specific outpatient treatment service was conducted.

Service users had a median age of 32 (range = 19–54). Most stimulant users were in part- or full-time employment (53.6%) and had stable accommodation (85%). There was a high rate of mental health comorbidity, with over half (52%) reporting a previous history of mental health problems, while one-third (33%) reported previous suicide attempts. There was a high rate (48%) of previous methamphetamine-associated psychosis, which was significantly correlated with frequency of use (x² = 13.698, p = 0.008).

This study supports the potential of a targeted and specialised treatment service as a means of early intervention for stimulant users. The high prevalence of methamphetamine-associated psychosis history in this group suggests that frequent use of stimulants increases the risk of psychosis, even among high-functioning individuals.

Multiple barriers contribute to low rates of help-seeking for problematic alcohol and other drug (AOD) use in Australia, and highlight the importance of flexible delivery models. This study explored the characteristics of clients accessing a national AOD online counselling service (Counselling Online) over time and across jurisdictions.

2003 clients completed a brief demographics questionnaire before commencing their Counselling Online session. Demographic (e.g. gender, primary drug of concern) and service provision (timing of session, length of session) characteristics were explored to build a profile of individuals accessing online support for AOD concerns.

Service provision and client characteristics remained relatively stable over time; alcohol remained the most common drug of concern, but methamphetamines overtook cannabis as the second most common drug of concern. Consistency in characteristics was also observed across states and territories, except for clients in the Northern Territory, where amphetamines were the most common primary drug of concern, and counselling sessions were significantly longer.

Counselling Online continues to be a wide-reaching, easily accessible service for those concerned about their or others substance use. The characteristics of clients who access the service also suggest that it is responsive to contemporary needs and concerns.

The current paper aims to provide an overview of methamphetamine in its historical context, integrated with a current understanding derived from animal studies and clinical experience.

Despite over a century of clinical experience, methamphetamine remains a troublesome substance. There remains an urgent need at multiple levels from various sectors to combat this ongoing problem, and psychiatry has an essential role in this endeavour.

The Internet is increasingly used in mental health service delivery, but there are significant potential barriers to Internet access for persons with severe mental illness (SMI). There is a need to understand this group’s access to, and confidence with using, the Internet, and current views on using online resources as part of mental healthcare.

A survey was conducted of 100 consumers attending a specialist mental health service in Melbourne, Australia.

Approximately three-quarters of participants had regular access to the Internet, and two-thirds used the Internet weekly or more. Half of the sample used email at least weekly, and a third were regular users of social networking sites. Internet access was often via mobile devices. Only a minority of participants used the Internet for mental health information, with video streaming and general websites accessed more often than peer forums for mental health content. Most participants were positive about their mental health worker using tablet computers with them in appointments for delivery of mental health materials.

Most people with SMI are active Internet users and, therefore, able to use interventions online.

Many models of community-based mental health crisis teams have been reported. We present our experience of an outreach team made up of a paramedic and mental health nurse.

A proof-of-concept was conducted in Western Sydney. The primary outcome was the proportion of patients where the team were able to facilitate the most appropriate care.

Nearly 70% of patients were able to be treated outside the Emergency Department, with about two-thirds being transported directly to a mental health facility.

We have demonstrated that our model of care is successful in enabling appropriate physical and mental health care for patients suffering an acute mental health crisis.

We aimed to determine characteristics of patients receiving Medicare-funded face-to-face consultations by psychiatrists in a rural service with an established telemedicine service.

For this study, 55 case-managed patients from four rural community mental health teams in South Australia provided information through questionnaires regarding psychological symptoms, quality of life, body mass index (BMI) and gave access to their Medicare data.

In a logistic regression, it was found that being younger was more likely associated with a Medicare psychiatric consultation (p<0.05). Participants with at least one recorded visit to a Medicare psychiatrist consultation also tended to have lower levels of psychological distress at the end of the 4-year period, have a higher BMI, and more general practitioner consultations.

The study provides clinicians and policy makers with preliminary information on the subtle differences in clinical profile of patients seen by Medicare-funded psychiatrists within an established state-managed telepsychiatry service.

People who are homeless have high mortality and morbidity, including from metabolic disorder. The aim of this study was to report on the characteristics and progress of the metabolic health of people attending a metabolic clinic at a homeless men’s shelter.

Homeless men attending the clinic were assessed by measuring their weight, height, body mass index (BMI), waist circumference, blood pressure, blood lipids, fasting blood glucose and, if indicated, HbA1c. The sample characteristics of people who attended once (one-off clients) were compared to those who attended on more than one occasion (returning clients). Changes in health status were examined among returning clients by comparing baseline results to those at their last clinic visit.

Baseline data were recorded on a total of 136 men, of whom 126 had a consultation with a general practitioner and at least one blood test. The 136 clients had a median BMI of 27.4 kg/m². Forty-three were obese (BMI ≥30 kg/m²), 18 had class II obesity (BMI >35 kg/m²) and seven were underweight (BMI <20 kg/m²). Sixty-five had an intervention for either a newly diagnosed condition or a change to existing medical treatment. Seventy-six returning clients were seen on an average of 2.3 further occasions. Returning clients had significant improvements in measures of metabolic health.

Homeless people in Sydney appear to be at a high risk of metabolic disease. The feasibility of a metabolic health clinic was demonstrated, and an encouraging improvement in some health indicators was found.

Australia has been at the forefront of appropriate early intervention. Prevention of mental illness in infants by early identification and intervention in the mental health of their mothers has stalled since the cessation of funding through the National Perinatal Depression Initiative (NPDI, 2009–2015). Whilst screening for maternal mental illness has been widely implemented throughout Australia during the last two decades, services are now diminishing and great opportunities to ride the crest of a wave for appropriate mental illness intervention are receding. Reviews of history and interventions internationally may help guide future directions.

Advocacy through across-agency and across-political-party support has been markedly successful for perinatal and infant mental health in the United Kingdom. A solid foundation exists in Australia. Australian psychiatrists have the ability to continue to change the face of prevention and early intervention.

Reducing or eliminating seclusion from mental health care settings has been a national priority for Australia since 2005. This paper describes Australia’s national seclusion data collection, and summarises changes in seclusion rates in Australian public mental health services.

Seclusion events per 1000 patient days were calculated from 2009–2010 to 2014–2015 utilising state and territory administrative data sources. Combined national data were used to calculate results for a number of service characteristics, such as target population and location of the service.

The rate of seclusion events decreased by 43% over the 6 years. Child and adolescent services reported consistently higher rates of seclusion, but a shorter duration of seclusion episodes, compared with other service types. There is high variation in seclusion rates between individual services (range 0.0–53.0 seclusion events per 1000 bed days in 2014–2015).

Seclusion event rates in Australia’s specialised public acute mental health hospital services are declining. The use of existing administrative data was instrumental in establishing a national data source to facilitate the monitoring and reporting of progress of seclusion reduction strategies.

The objective of this study was to conduct a systematic review of evidence for the accuracy of the Kimberley Indigenous Cognitive Assessment (KICA) tool in supporting the diagnosis of dementia in Indigenous Australian populations.

Cross-sectional diagnostic accuracy studies of the KICA with an appropriate reference standard published to November 2015 were included. Comparison to an alternative cognitive assessment tool was required in non-remote populations. Case control analyses were excluded.

Four studies were included: one of the KICA-Cog and KICA-Carer, one of the KICA Screen, and two of the modified-KICA. All tools developed for remote populations had a sensitivity of ≥76% and a specificity of ≥71% for the diagnosis of dementia. The KICA-Cog and KICA-Carer conducted in series had the highest sensitivity and specificity (91% and 94% respectively). In an urban and regional population, the mKICA had similar accuracy to the Mini-Mental State Examination (MMSE) (AUC 0.93, 95% CI 0.88–0.99 vs 0.94, 95% CI 0.89–0.99). Key risk of bias limitations related to lack of pre-determined cut-points and population selection methods.

The use of the KICA in remote Indigenous Australians may assist in timely diagnosis of dementia in this population. Using the KICA-Cog and KICA-Carer in series may maximise specificity, decreasing false positive results without compromising sensitivity.

To explore users’ views of, and experience with, the Here and Now Aboriginal Assessment (HANAA), an instrument developed for screening social and emotional wellbeing (SEWB) in Aboriginal adults. Over the last few years the HANAA has been widely disseminated across Australia.

All those on our database who had requested the HANAA package were contacted by email and invited to participate in the evaluation by completing an online survey.

A total of 38 responses were received; the response rate was 36%. All 10 HANAA domains were highly rated by respondents; the overall mean score was 8.3/10. Each domain was assessed using a dichotomous scale of ‘problem’ or ‘no problem’ which respondents rated as being very useful; the mean score was 8.4/10. The mean score for the ‘recommendation’ section at the end of the HANAA was 7.2/10.

Respondents reported a high level of utility and cultural applicability of the HANAA’s assessment domains, semi-structured narrative style of administration and simple rating system. The HANAA is making a useful and practical contribution to the assessment of Aboriginal SEWB at a community level. Recommendations for future work on the HANAA include consideration of addition of a personality domain and development of a child and adolescent version.

The aim of this paper is to outline engagement and practice principles for psychiatrists contributing to responses to critical incidents, based on three decades of experience in remote Indigenous Australia.

Psychiatrists have important roles in these settings and situations, which should be considered in advance and informed by cultivated relationships.

We aimed to find and explore the earliest available New South Wales asylum medical records to identify any management or therapeutic data that might be of interest to the psychiatric field.

The earliest known existing records of New South Wales asylum data are from Tarban Creek Asylum. After almost two centuries the preserved records allow insight into treatment used in early colonial Australia, including the scarcely remembered seton therapy. This finding highlights the importance of preserving historical records. It also demonstrates the necessity and/or evolving wish within the colony to care for patients with perceived mental health difficulties based on a shared medical culture inherited from techniques used in Britain.

To scope the history of forensic mental health services in Western Australia since colonisation.

A range of primary sources, including archives, reports, and oral histories was consulted.

Forensic mental health services were identified as historically poorly managed, under-resourced, and inconsistently delivered.

Current problems with forensic mental health services may be linked to historical factors.

This paper describes the psychotherapy registrar position developed at St Vincent’s Hospital Melbourne in response to the Australian Government’s Specialist Training Position initiative of 2009. This impressionistic piece outlines features of the registrar’s clinical work, supervision and professional development. This paper will focus on: 1) the history of the position; 2) its developmental function embedded within the clinical responsibilities of the role; 3) how this position is different from the existing Royal and Australian and New Zealand College of Psychiatry psychotherapy training requirements; and 4) infrastructure issues of the position.

This psychotherapy registrar position is a novel role that provides an opportunity to work in an intensive and sustained way with patients and within multidisciplinary teams whilst being supported by supervision and a rich teaching milieu. It offers experience of psychotherapeutic work not usually available in public mental health services. It thus assists the development of psychotherapeutic skills that are likely to enhance the future practice of those undertaking the role.

We aim to summarise the active learning literature in higher education and consider its relevance for postgraduate psychiatry trainees, to inform the development of a new Formal Education Course (FEC): the Master of Medicine (Psychiatry) at the University of Sydney.

We undertook a literature search on ‘active learning’, ‘flipped classroom’, ‘problem-based learning’ and ‘psychiatry education’.

The effectiveness of active learning pedagogy in higher education is well supported by evidence; however, there have been few psychiatry-specific studies. A new ‘flipped classroom’ format was developed for the Master of Medicine (Psychiatry).

Postgraduate psychiatry training is an active learning environment; the pedagogical approach to FECs requires further evaluation.

This article discusses the real-life experience of two senior registrars who are approaching the end of their training under the 2012 Competency Based Fellowship Program. We have shared some practical tips to assist trainees in completing the Program, with particular emphasis on examination preparation.

Whilst stressful at times, we believe that going through the Competency Based Fellowship Program has helped us build our knowledge, skills base, and expertise for practising psychiatry as consultants.