FRANZ RESCH, KEYNOTE ON ADOLESCENTS AT RISK – ESCAP 2019 VIENNA

New morbidity: the switch from guilt to shame

Professor Franz Resch (Heidelberg).“More than fifteen percent of our adolescents are at a high risk of developing mental health problems, related to their adaptation to the world around them. Being a young person today, trying to become an adult, is not as easy as it was in my youth. Changing into the new ways of living as an adult, and forming one’s identity, self-esteem and learning how to connect to others has become a complicated task”, says Franz Resch (Vienna, 1953), professor at the Heidelberg University in Germany, head of the Heidelberg clinic for child and adolescent psychiatry, and keynote speaker at the 2019 ESCAP Congress in Vienna on The new morbidity, changing risks in changing environments.

Professor Resch claims that this increased risk for adolescents is reflected by a high prevalence of mental disorders among adolescents: “In our studies, we distinguish three apparent reasons and three real reasons that explain the higher prevalence. Apparently, we have a higher awareness and less taboos for mental disorders in children these days, new definitions in the DSM-5 influence the prevalence figures, and we tend to medicalize social problems more than we did before. True reasons, more importantly, are the earlier onset of disorders, inequality in socio-economic status, and the developing standard of our medical standards, resulting in – for example – higher vulnerability as a result of the increased chance of survival after preterm birth.”

AtR!sk
The many studies, executed by Resch and his Heidelberg team since the late eighties, were focused on risk behaviour, and non-suicidal self-harm in adolescence. This has led to a better understanding of the prevalence and dynamics of this behaviour, showing a trend that had been defined before as a new morbidity. And to the foundation of AtR!sk, an outpatient clinic that supports “adolescents exhibiting risk-taking and self-harm behaviour, and to their caregivers. Adolescents are motivated to actively cope with their problems and to question their ‘illusory’ solutions to relationship issues and other difficulties.”
New morbidity – or rather: new epidemics – was defined by Hans Georg Schlack and Knut Brockmann in their chapter on the influence of social factors on the health and development of children for a paediatric manual (2014), as a pattern of disorders that appears to be different from a few decades ago. This is a shift of focus from primarily physical diseases towards more frequent functional and mental disorders and from acute to chronic illnesses. The difference is not found in the disorders themselves – the authors sum up: emotional disorders, behavioural problems and disorders, developmental disorders, obesity and eating disorders, and substance abuse – but in the epidemic accumulation.

The spirit of times
These new epidemics come along with the present spirit of times – der Zeitgeist – says Resch, and in particular with the huge leap of communication technology. “We have so many new means in the modern and post-modern world of information technology that have revolutionized our way of connecting with each other. All young people are now connecting to each other in virtual realities, and new problems have arrived along with that, such as cyber-mobbing, and new intrusive ways of non-physical interaction, channelled through social media.”

– Schlack and Brockmann mention a shift of focus, or as they say “‘Schwerpunktverlagerung”, in morbidity. From physical to mental, from acute to chronic. How would you explain this evolutionary process?
“In the last ten to fifteen years we have seen puberty to start at earlier ages. Therefore, we believe that some of the adult problems that used to appear at the age of over eighteen, now have come down to the age of fifteen to sixteen. When I started in child psychiatry, bulimia nervosa was a relatively rare condition in eighteen to twenty year olds. Ten years later the disorder was relatively rare in the ages below sixteen, but became more usual above that age. Now we see many young girls with panic attacks at the age of fourteen...”

Earlier onset
“Possibly, the total prevalence of mental disorders – in young people and adults – is not increasing, but some of the real increase in child psychiatry is due to the fact that some disorders start earlier. Also, the pathology of disorders develops differently from an early age onset. This lays a heavier burden on child psychiatry and it may cause a shift in adult psychiatry later on, even though some adult psychiatrists are not convinced about this development.”

– This means that clinicians are confronted with symptoms, earlier than they ever learned in their training days. What does this mean for them, and for treatment?
“Yes, many therapists notice that we have a lot of very young people with a high level of mental disorders that used to occur at an older age. In borderline syndrome for instance, the official age limit has been dropping from above eighteen to sixteen, and today I know many cases of borderline below the age of fourteen. We have to adapt treatments that are evidence-based for adults, for use in adolescents. I am sure, we can safely use many aspects from the adult therapies, but of course there are additional aspects: how to get on with the parents, how to treat the parents, how to include the system or social environment. There are changes in the view on what level of experimentation should be allowed – if a certain therapy is not yet available for under eighteen, we may have use the adult version both in psychotherapy as also pharmacotherapy. Every child psychiatrist knows the dilemma: in the narrow sense, the drugs are often not allowed for use in children – but we use them because we have no alternative.”

Updating knowledge on adults
– Today, therapists are not trained to recognize a personality disorder in a fourteen-year-old.
“It is very important that child and adolescent psychiatrists get to know all disorders up to the age of thirty, because these dimensions are shifting right now: many psychopathologies are now appearing at earlier ages. More than ever, we have to update our knowledge, as we should stay in connection with the social environment of our adolescent patients – there is no doubt about that.”
“In Heidelberg we have a common ward, together with the adult psychiatrists for fifteen to 25 people. I think this is a better model than inventing a new category of ‘in between’ psychiatrists for adolescents. Ours is a cooperative model of looking at transition. I believe this is the better way.”

– What changes do you observe in the way that young people form their adult identity?
“Finding identity may be harder for young people today. They act from an increased feeling of shame, compared to older generations. When I was young, we had a preponderance of guilt. We had to deal with many laws and regulations, and there were many things that we were not allowed to do when we grew up. The adults that I experienced in my youth, were survivors of a Nazi generation who seemed very strong to me – they were convincingly taking their position and made us feel small. Living our life through the many things that were forbidden, we were made feeling guilty in many situations. But this also created a certain solidarity between peers.”

From guilt to shame
“In the present day young people have a strange feeling of shame. The most important feeling of this generation is shame, mostly for not taking the advantages that they have at arm’s length. Today’s youngsters inherit a world in which they are told that everything is feasible. So when you fail, it will always be your fault, nobody else’s. As long as you are winning, everything is OK, but you are not allowed to fail. You have to be in a good physical shape, a skilled communicator, intelligent, beautiful… You have so many chances to be all of that – so if you can’t, you obviously are a loser. One in six adolescents consequently feel that they are losers.”

Self-objectification
“This is the switch from guilt to shame. And in the process of trying to be lucky or successful, young people use themselves as tools for their own strive – the German term we use here, is Selbstverdinglichung, self-objectification. These individuals become interchangeable objects in the process of pursuing their purposes. They ‘use themselves’ for becoming winners, and they behave towards themselves as if they were the instrument, not the operating subject. In self-harm for example, the cutting is often a result of considering themselves things.”
In their paper ‘New morbidity and the spirit of times’, Franz Resch and Peter Parzer take up this aspect as a mission, not only for therapists but for all adults in society:

  • “(..) self-objectification and addictive self-consumption are finally nourished by the longing to assert oneself and to define one's own self. This paradox can only be resolved by us adults through lived communality in the sense of differentiated inter-subjectivity. This is one of the biggest challenges for all of us.”

Access to care
The Heidelberg outpatient clinic for adolescent risk-taking and self-harm, AtR!sk, opened its doors in 2013, inspired by and developed in close collaboration with the HeadSpace team of professor Patrick McGorry (Melbourne). Franz Resch: “We copied the AtR!sk concept from the Australian model of my good friend Pat McGorry, with whom I also worked on early episode psychotic conditions in young people. My co-worker, professor Michael Kaess, had the chance to go down under and work with Pat – so we are very familiar with their programme. We have adapted it to the German institutional system, but the basic idea is the Australian HeadSpace concept."

– Accessibility was an important aspect for HeadSpace.
Professor Michael Kaess (Heidelberg)
Unfortunately, we do not have the inner city facilities like in Melbourne that functions as an open club house, but we do organize open door days, we have developed smart phone Apps to communicate with patients, a chatroom where young people can ask questions and get answers, and we have no waiting list. Patients are always welcome within a week – to access a traditional psychotherapy practice in Germany today, you usually have to wait for months. Also, we are currently running a big study on accessibility, with Michael Kaess as a project leader: how can we lower the threshold as much as possible, and how can we use social media to achieve that?”

Patients do not show up
– Patrick McGorry warns us, not to fool ourselves with the prevalence figures. To his estimate, less than fifty percent of the actual patients show up at the facilities for treatment.
“That is true for Germany too. Perhaps this is less of a problem in and around Heidelberg, where we have a very tight net of mental health caregivers. With this availability, I expect that a higher percentage of patients may make use of our care. But in other parts of Germany, like the eastern regions, there is a very high amount of patients that never show up in psychiatry. Nevertheless, the situation in Germany is relatively good compared to other countries. In Australia, for example, they have to deal with extreme distances and remote areas without psychiatric facilities – those problems we do not have in mid-Europe. In spite of that, we know that only three to five percent show up at our facilities, out of the fifteen to twenty percent of young people that may need help. The top of the iceberg gets to us, so to speak. We are also aware that we do not see some of the very ill, with severe developmental problems and great difficulty to function in society, because they are stuck in families where everybody is so paranoid about helping systems that nobody – the parents nor the children – are willing to take advantage of the available care.”

The ground floor of society
– Do you think these hidden mental illnesses are a threat to society?
“Yes, I do. We know that the global burden of mental disorders will be leaning stronger and stronger on society. This is underestimated by politicians. Those who do not get help, will lose acceptance and their social connections, and eventually they will end up on the ground floor of society. This is a matter of money: the political system of economic polarisation. Our society does not let the lower incomes take part in the increase of wealth – not nearly as much as the very high incomes do.”

Dangerous compound
“Very rich people get richer on one hand, and the group of relatively poor people is getting larger and larger, while the new luxuries and advantages that the economy brings are not within their reach. We are losing the group in the middle – the Mittelschicht –,  those who traditionally work hard for their money, but they have experienced in the last decades that their standard of living only increased by a few percent. They also see that in the meantime, the living standard of the millionaires has improved by twenty to thirty percent.”
If this would lead to a situation where the poor and the ‘almost poor’ do not accept care, or do not know how to access mental health services, this is a social compound that may become dangerous for society. Statistics tell us already that out there somewhere, we should look for many more young patients from poor families than we are actually seeing now – we are working hard to convince these children and adolescents to access our services. I can imagine that, in countries where this transfer effort is not made, mental health problems in families with children become a real big problem. These children, grown up in poverty, have a very high risk of not finding their place within society. We are very glad that unemployment has decreased, after the recent economic crisis. But if we look at young people in Germany in 2017, their unemployment figures are around double of those in adults – in Greece, Spain, Italy and Portugal, unemployment of young people is even three times as high. Politicians give far too little priority to the social wellbeing of adolescents.”

Avoiding the spotlights
What could be done about this situation?
“Much more should be known about the way we are able to offer high quality mental health care. For example, by psychotherapy. What we can do and what benefits it brings to people with mental health problems, should be much more out in the open, in the media and in the public debate. The problem is that we – the therapists – hardly take the floor and speak out. We are always hiding in our own ‘hidden world’. Psychological therapists do not want to be part of what they fear as the big media circus. They do not like the spotlights. Unfortunately, there are only a few exceptions. In general, they are too modest and in some way introverted.”

Young people in an aging world
Frans Josef Radermacher, professor of artificial intelligence.
“When addressing politicians, we have one thing that is against us as therapists for children and adolescents, and that is the fact that society today consists of more old people than young. Politicians who want to be elected, subsequently go for the old ones, not the young. That is why very few politicians will stand up for the interests of young people – our next generation. I used to be president of the German Child Liga, where we placed this problem and suggested that parents of children should have more votes, to put some weight against the powerful but aging majority. It was not taken seriously…”

– A relatively small, next generation will have to care for a very large group of elderly people from a few years’ time.
“Yes. This is a problem in society that we do not really face. Looking at the future we have to solve these things. I am fond of the ideas of Franz Josef Radermacher, professor of artificial intelligence in Ulm, a scientist and philosopher, who is looking at the technological needs of society in the future. He says that we have to face the problem of ecology and protect our natural resources, not waste them as we do now. Then we have to face the economic issues, such as the polarisation between the rich and the poor. And thirdly, we should create a new human solidarity, a more cooperative attitude towards each other. If we don’t, we will roll back from our democratic society and liberal values, into times of absolutism. A tendency that we have already seen in Turkey, in Hungary, in Poland and in the United States of America – countries where we see that right-wing politicians seem to strive for modern dictatorship. The problem is that the expanding group of poor and neglected people that I have mentioned before, who are thrown back to the ground floor of society, will become the electoral support for these populist, potential dictators. These people are disappointed and not interested in an open society, and the more these people feel that they are losing out, and they don’t get their part of prosperity, not sharing the increase of economic possibilities, the angrier they get and give their votes to antisocial forces.”

Procured social values
– Is this a political bond between a professor of artificial intelligence, and a professor of child and adolescent psychiatry?
“One of the lessons that I have learned, is that my job is very political indeed. And yes, child and adolescent psychiatry is politically perhaps as relevant as artificial intelligence. Child psychiatrists cannot lean back and say that only natural sciences are the basis of their work. We are also in the position of having a very profound look into the processes of society, through caring for the wellbeing of children who have problems with adapting to that world. Today this includes witnessing procured social values to be thrown into the depth – what we call abgründen.”

– A child and adolescent mental health worker is also an investor in future generations. Could that be the positive side to it?
“We try to invest in the future. This is one of the beautiful facets of our job. In many cases, small interventions can do so much, building on the developmental potential of young people. We just help them get over some problems that they have and then they get on and reach their goals… That is beautiful: we are helping them in a real way.”
“The core matter is: the emotional dialogue between the parent and the child is essential for the development of their personality, their identity and self-esteem. Societal influences have an impact on this emotional dialogue. Spoiling this emotional dialogue between parents and children makes children vulnerable. Therefore, our aim must be to foster and to help the parents and the children to get on with this dialogue.”

Respond to this story.
Read more: Franz Resch about psychotherapy for child psychiatrists.

This story: courtesy of the Dutch Association for Child and Adolescent Psychotherapy (VKJP).

  • Publications & references

    Selection of related publications:

    Resch, F., Kaess, M. (2018). Flucht in die Scheinwelt? Identität und Risikoverhalten bei Jugendlichen. Klinik für Kinder- und Jugendpsychiatrie, Universitätsklinikum Heidelberg.

    Resch, F., & Kaess, M. (2018). Lena Eppelmann1, PeterParzer1, Christoph Lenzen1, Arne Bürger2, Johann Haffner1. Zeitschrift für Kinder-und Jugendpsychiatrie und Psychotherapie1, 8.

    Sawyer, S. M., & Patton, G. C. (2018). Why are so many more adolescents presenting to our emergency departments with mental health problems? The Medical Journal of Australia208(8), 339-340.

    Buzzell, G. A., Troller-Renfree, S. V., Barker, T. V., Bowman, L. C., Chronis-Tuscano, A., Henderson, H. A., ... & Fox, N. A. (2017). A Neurobehavioral Mechanism Linking Behaviorally Inhibited Temperament and Later Adolescent Social Anxiety. Journal of the American Academy of Child & Adolescent Psychiatry56(12), 1097-1105.

    Kaess, M., Ghinea, D., Fischer-Waldschmidt, G., & Resch, F. (2017). The Outpatient Clinic for Adolescent Risk-taking and Self-harm behaviours (AtR!sk) – A Pioneering Approach of Outpatient Early Detection and Intervention of Borderline Personality Disorder [Die Ambulanz für Risikoverhalten und Selbstschädigung (AtR!sk)–ein Pionierkonzept der ambulanten Früherkennung und Frühintervention von Borderline-Persönlichkeitsstörungen]. Praxis der Kinderpsychologie und Kinderpsychiatrie66(6), 404-422.

    Resch, F., Parzer, P. (2017). Neue Morbidität und Zeitgeist: Zum Problem des emotionalen Dialogs in sozialen Entwicklungsräumen. Klinik für Kinder- und Jugendpsychiatrie, Universitätsklinikum Heidelberg. [link]

    Resch, F. (2017). Kinder-und Jugendpsychiatrie und Psychotherapie–Ein RundblickChild and adolescent psychiatry–a panorama. neuropsychiatrie31(3), 127-132.

    Kaess, M., Brunner, R., & Chanen, A. (2014). Borderline personality disorder in adolescence. Pediatrics134(4), 782-793.

    Schlack, H. G., & Brockmann, K. (2014). Einfluss sozialer Faktoren auf Gesundheit und Entwicklung von Kindern. In Pädiatrie (pp. 152-155). Springer Berlin Heidelberg.

    Radermacher, F.J., Beyers, B. (2011). Welt mit Zukunft – Die ökosoziale Perspektive. Murmann Verlag Hamburg.

    Brunner, R., Parzer, P., Haffner, J., Steen, R., Roos, J., Klett, M., & Resch, F. (2007). Prevalence and psychological correlates of occasional and repetitive deliberate self-harm in adolescents. Archives of pediatrics & adolescent medicine161(7), 641-649.

  • AtR!sk self-screening

    If you answer "YES" to any of the following questions, we could be a potential source of quick professional help.

    • Do you take illegal drugs?
    • Do you drink until the film breaks or quite frequently?
    • Did you deliberately hurt yourself lately?
    • Do you often have changing or unprotected intercourse?
    • Do you spend most of your free time with the internet and computer games and are you having trouble with your parents?
    • Do you sometimes think about taking your life?
    • Have you already come into conflict with the law?

    Questionnaire from the AtR!sk web page. The Outpatient Center for Risk Behaviour and Self-Injury (AtR!sk) opened in April 2013 to help reduce long waiting times for adolescents with risk behaviours and self-harm, allowing for faster specific diagnostics and treatment.

  • ESCAP 2019 Vienna congress

     View the preliminary programme of the ESCAP 2019 Congress in Vienna.