Journal articles on the topic 'Psychotherapy patients Australia'

Objectives: 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. Conclusions: 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.

Frances Tustin (1913-1994) was a British child psychotherapist who trained at the Tavistock Clinic in London and who was an analysand of Wilfred Bion. She is internationally recognised for her work with autistic children and wrote around thirty articles and four books: Autism and Childhood Psychosis (Tustin, 1972), Autistic States in Children (Tustin, 1981), Autistic Barriers in Neurotic Patients (Tustin, 1986), and The Protective Shell in Children and Adults (Tustin, 1990). In 1995, a year after Tustin’s death, the Frances Tustin Memorial Trust was established by Dr Judith Mitrani (see the Frances Tustin Memorial Trust, 2012). The Trust is dedicated to the teaching, expansion and extension of Frances Tustin’s work on the understanding and treatment of autistic spectrum disorders in children, adolescents and adults. This includes the sponsorship of international conferences on Tustin’s work, which have been held in London, UK (2004); Caen, France (2005); Venice, Italy (2006); Berlin, Germany (2007); Tel-Aviv, Israel (2008); and, this year in Sydney, Australia. This Sixth International Conference, entitled On Bringing Patients to Life, was organized by the Trust, in conjunction with the Australian Psychoanalytical Society, the New South Wales Institute of Psychoanalytic Psychotherapy, The Institute of Child and Adolescent Psychoanalytic Psychotherapy, and the Couples and Family Psychoanalytic Psychotherapy Association of Australasia.

Objective: To examine laws in three Australian jurisdictions that prohibit therapy to change or suppress a person’s sexual orientation or gender identity. Conclusions: The laws in Victoria and the ACT provide inadequate protection for clinically appropriate psychiatric practice and may deprive patients of mental health care.

Objective: As in Australia, demand for psychotherapy is rising in Britain, and the wide variety of psychological treatments available within the National Health Service (NHS), the independent sector, and voluntary agencies leads to uncertainty about which patients are most suitable for which type of psychotherapy, as well as the appropriate balance between psychological and pharmacological interventions. This paper describes how Birmingham Health Authority (HA), the largest HA in England and Wales with a population of just under one million, developed and implemented an evidence-based strategy for the use of psychotherapy services. Method: A literature search and health needs assessment for psychotherapy in Birmingham was performed. Results: It was possible to estimate the need for evidence-based psychotherapy services using routinely available epidemiological data. By matching specific techniques to individual diagnosis and estimating the size of the population for whom this was appropriate, demand for psychotherapy exceeded service provision by a factor of four. Conclusions: The following steps were undertaken: (i) setting priorities for the commissioning of psychotherapy on the basis of the scientific literature including greater use of brief and focused forms of integrative therapy from a variety of psychotherapeutic schools; (ii) targeting interventions on the basis of objective criteria to ensure that patients were referred for the appropriate level and intensity of psychological intervention using the full range of available services within the NHS, the independent sector, and voluntary agencies; (iii) agreeing on an integrated treatment algorithm (ITA) for the use of the most cost-effective treatments while ensuring that a range of alternative interventions was available for patients for whom a first line therapy was not suitable. Such an ITA could be adapted to assist general practitioners in their management and referral decisions; (iv) sharing skills between specialist psychotherapy services and members of primary and mental health teams through training, supervision and consultation–liaison.

Objective: This paper reports the capabilities of mental health nurse (MHN) psychotherapists in Australia and their perceptions on how to best utilize their skills. Method: An MHN is a registered nurse with recognized specialist qualifications in mental health nursing. One hundred and fifty three MHNs completed an online survey; 12 were interviewed. Results: Three themes were derived from a qualitative analysis of the aggregated data: psychotherapy skills of MHN psychotherapists are under-utilized; these nurses bridge gaps between biomedical and psychosocial service provision; and equitable access to rebates in the primary care sector is an obstacle to enabling access to services. Conclusions: MHN psychotherapists are a potentially valuable resource to patients in tertiary and primary health care. They offer capacity to increase access to specialist psychotherapy services for complex and high risk groups, while being additionally capable of meeting patients’ physical and social needs. Equitable access to current funding streams including Medicare rebates can enable these outcomes.

The problems and goals approach (P&G) is a therapeutic assessment and intervention used in the behavioural psychotherapy field. P&G is a patient-centred, pragmatic technique in which the patient and health professional determine the patient?s problems and formulate realistic medium term goals based on measurable outcomes. P&G was utilised in the SA HealthPlus first round Coordinated Care Trial in South Australia with intervention patients who had chronic medical conditions. This article presents a case study from SA HealthPlus. The aim of this article is to introduce the practical workings of P&G and provide some observations about this technique.

OBJECTIVE: Restrictions on social interaction during the COVID-19 pandemic necessitated a rapid transition to telehealth to continue providing psychotherapy to people diagnosed with personality disorder. This naturalistic cross-sectional study evaluated the experiences of clinicians using telehealth for the first time to treat clients diagnosed with a severe personality disorder (complex and/or high risk presentation). METHODS: Thirty clinicians working at a specialist clinic for personality disorders completed an online survey during May-June 2020 in Melbourne, Australia. RESULTS: Despite having some initial technical issues, most participants rapidly and successfully connected with clients via phone and/or video-conference, recommencing individual and group evidence-based psychotherapies. Appointments were kept more reliably than when in-person treatment was offered. Issues around privacy, confidentiality, risk, quality of interaction, and treatment boundaries were raised, highlighting the need for specific guidelines and formal processes. However, clinicians’ awareness of some of the benefits of telehealth was evident, with most looking forward to using telehealth for some aspects of their work with clients and more generally into the future. CONCLUSIONS: This experience with delivering psychotherapy using telehealth during COVID restrictions suggests that it is an acceptable platform that can be managed safely for treating patients with severe mental illness in the short term at least. This outcome encourages the pursuit of efficacy studies to evaluate telehealth as a more equitable and accessible treatment modality.

Objective: The aim of this study is to determine the effects of experience on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Method: A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: years of psychiatric experience; higher medical qualifications; location and type of psychiatric practice; attitudes about senior psychiatrists and mentorship; changes in work practices over the career; and the perceived benefits and drawbacks of experience on psychiatric practice and case selection. Results: Of 1086 eligible subjects, 629 participated. Over 96% of respondents, particularly the younger and less experienced, believed that senior psychiatrists have wisdom to offer to junior colleagues. This wisdom principally related to mentor-ship/supervision. Increased ‘respect and tolerance’ of patients as a benefit of experience was more likely to be reported by respondents who were more experienced. Respondents more confident about treating younger patients and treating functional psychoses were more likely to be less experienced, as were those reluctant to take on psychotherapy cases. Those respondents reluctant to take on ‘dangerous or acting-out patients’ were more experienced. The field of psychiatric practice significantly influenced case selection. Conclusions: Senior psychiatrists have accumulated wisdom through experience that is sought by junior colleagues via mentorship. It is recommended that the RANZCP should specifically address the needs of early career and senior psychiatrists.

IntroductionDementia is one of the leading causes of mortality and morbidity in Australia. Attitudes towards dementia in the workplace, tailored adjustments for disability, and patient-centred ‘exit with dignity’ strategies are of objective and subjective importance to patient wellbeing. This study aimed to assess employment characteristics in those with newly diagnosed dementia, and engagement with multidisciplinary supports.MethodsAn audit of patients with diagnosis of dementia (n=136,age51–96 yrs,M:F1.1:1) and mild cognitive impairment (MCI)(n=28,age56–83M:F0.6:1) over a 16 month period in 2017–18 was performed using online server data collection and retrospective analysis of general and employment demographic characteristics, presenting clinical information, and care across clinical psychology, psychotherapy, occupational therapy, speech pathology, and dietetics.ResultsYounger onset dementia was present in 14(10%). Of the 122 dementia cases aged above 65 years, 24(20%) were employed-active, 98(80%) were retired, and none were unemployed. Approximately 5% had a background in healthcare. Allied health support was provided in 106 cases (78%) with ≥3 supports in 28(21%) and was more common in those who were retired(76%) versus employed-active (21%). Clinical psychology or psychotherapy support was provided in 50(37%) cases of dementia. ConclusionsThe onset of dementia often co-exists with active employment. Community perception of employment status in dementia would be of future research interest. Provision of multidisciplinary allied health supports in dementia may facilitate coping, adjustment and cooperative strategies for exit with dignity but further studies are required in this cohort.

AbstractObjective:People with a life-limiting physical illness experience high rates of significant psychological and psychiatric morbidity. Nevertheless, psychiatrists often report feeling ill-equipped to respond to the psychiatric needs of this population. Our aim was to explore psychiatry trainees’ views and educational needs regarding the care of patients with a life-limiting physical illness.Method:Using semistructured interviews, participants’ opinions were sought on the role of psychiatrists in the care of patients with a life-limiting illness and their caregivers, the challenges faced within the role, and the educational needs involved in providing care for these patients. Interviews were audiotaped, fully transcribed, and then subjected to thematic analysis.Results:A total of 17 psychiatry trainees were recruited through two large psychiatry training networks in New South Wales, Australia. There were contrasting views on the role of psychiatry in life-limiting illness. Some reported that a humanistic, supportive approach including elements of psychotherapy was helpful, even in the absence of a recognizable mental disorder. Those who reported a more biological and clinical stance (with a reliance on pharmacotherapy) tended to have a nihilistic view of psychiatric intervention in this setting. Trainees generally felt ill-prepared to talk to dying patients and felt there was an educational “famine” in this area of psychiatry. They expressed a desire for more training and thought that increased mentorship and case-based learning, including input from palliative care clinicians, would be most helpful.Significance of Results:Participants generally feel unprepared to care for patients with a life-limiting physical illness and have contrasting views on the role of psychiatry in this setting. Targeted education is required for psychiatry trainees in order to equip them to care for these patients.

Background Digital mental health interventions stand to play a critical role in managing the mental health impact of the COVID-19 pandemic. Thus, enhancing their uptake is a key priority. General practitioners (GPs) are well positioned to facilitate access to digital interventions, but tools that assist GPs in identifying suitable patients are lacking. Objective This study aims to evaluate the suitability of a web-based mental health screening and treatment recommendation tool (StepCare) for improving the identification of anxiety and depression in general practice and, subsequently, uptake of digital mental health interventions. Methods StepCare screens patients for symptoms of depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder scale) in the GP waiting room. It provides GPs with stepped treatment recommendations that include digital mental health interventions for patients with mild to moderate symptoms. Patients (N=5138) from 85 general practices across Australia were invited to participate in screening. Results Screening identified depressive or anxious symptoms in 43.09% (1428/3314) of patients (one-quarter were previously unidentified or untreated). The majority (300/335, 89.6%) of previously unidentified or untreated patients had mild to moderate symptoms and were candidates for digital mental health interventions. Although less than half were prescribed a digital intervention by their GP, when a digital intervention was prescribed, more than two-thirds of patients reported using it. Conclusions Implementing web-based mental health screening in general practices can provide important opportunities for GPs to improve the identification of symptoms of mental illness and increase patient access to digital mental health interventions. Although GPs prescribed digital interventions less frequently than in-person psychotherapy or medication, the promising rates of uptake by GP-referred patients suggest that GPs can play a critical role in championing digital interventions and maximizing the associated benefits.

An analysis was carried out on Medicare data to find out if there are inequalities in the geographical distribution of private psychiatric services in Australia. The number of psychiatric services and persons becoming patients per 100,000 population was calculated for each federal electorate for the year 1985/86 and related to social indicators derived from the 1986 census. As a comparison, services provided by consultant physicians were analyzed as well. The data were based on the electorate of the patient rather than the electorate of the practitioner. Consultant psychiatrist services were found to be received more often in high socio-economic status electorates and those with older populations, and less often in rural areas. A similar pattern was found for consultant physician services, although the relationship with socio-economic status was not as strong. Frequent psychiatric consultations of longer duration, which are an indicator of insight psychotherapy, were more common in higher socioeconomic status electorates. A limitation of the Medicare data is that they cover only private services. To overcome this limitation, a supplementary analysis was carried out on the distribution of consultations for mental disorders using data from the National Health Survey. These data confirmed that individuals of high socio-economic status with a mental disorder are more likely to receive specialist treatment.

A random sample of psychiatrists was asked to supply details about their last 20 patients. Sixty percent responded. The median patient in treatment was aged 36 and saw a psychiatrist in office practice once a month over a three year period. Forty-one percent of the patient case load suffered from a psychotic disorder, 39% from a neurosis, and 6% from a personality disorder. Marital problems, problems in living and drug or alcohol dependence were infrequent reasons for consultation. Two positive conclusions were drawn: that the case load reflected the morbidity in the community, and that the prognosis for patients with personality disorders was better than usually expected. There were two areas of concern that may need attention: that insight and group psychotherapy require substantial numbers of treatment hours, and that behavioural psychotherapy is rarely used for patients whith neurotic conditions.

Objectives: 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. Conclusions: 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.

Practising psychiatrists' views about the treatment of schizophrenia were investigated as part of a Quality Assurance Project. A questionnaire which asked for treatment recommendations for each of four case descriptions of patients with schizophrenia was mailed to a one-in-six random sample of Australian psychiatrists; 90% responded. Psychiatrists almost uniformly advocated the use of antipsychotic drugs and usually recommended concurrent supportive psychotherapy or family/social intervention procedures. The recommendations varied systematically, according to the initial history obtained and to the initial response to treatment.

Introduction Traditional Chinese medicine (TCM) has long recognised the use of acupuncture in psychological medicine. Classically the acupuncture meridians or channels are each linked to particular emotions, for example, joy and sadness (heart channel), panic and anxiety (kidney channel), anger and frustration (liver channel). By correct diagnosis, acupuncture intervention can be useful in the restoration of emotional well-being. Today it is realised that this restoration of emotional health is due to neuromodulation at the higher centres. Results of the NIH funded depression study by Allen, Hitt and Schnyer (1998) were encouraging. The study demonstrated acupoint specificity (p < 0.05) for mood disorders. Unfortunately, the study was single blinded. This study is based on the NIH study. The research team hoped to reproduce the significant results achieved then. With laser as the modality, the advantages were obvious: non-invasive modality, randomised double blind control achievable, no infection risk and ease of training community-based doctors to utilise the technique. Method This pilot study utilised laser acupuncture in an outpatient population with mild to moderately severe depression with Beck Depression Inventory (BDI) scale of 12 to 30. Normal was less than or equal to BDI of 10. Recruitment was through family practices (called general practices in Australia) and newspapers. Recruits were each screened by a psychiatrist to confirm their suitability. They were then randomised into sham laser and true laser groups. Each patient received twice a week sessions for a month, followed by once a week sessions for another month. BDI scores were taken fortnightly to ensure none of the patients deteriorated. The acupuncturist was also blinded. BDIs were repeated at one month and three months post laser. Results Thirty patients were recruited and randomised into true and sham laser. Four patients were withdrawn, two from each arm of the study. The rest completed the laser sessions. Of those who completed the study, one patient did not respond to any of the post laser follow up BDI requests. Another patient did not complete the three-month follow up BDI. Results showed a markedly significant improvement in the active group (p< 0.001) at the end of the course of treatment with a sustained difference one month after treatment (p<0.05). Discussion The markedly significant results were unexpected. They do however make laser acupuncture a serious contender as a third standard management option in the treatment of depression in the community. Laser acupuncture could stand alone, or be used together with counselling, psychotherapy or drug therapy. These latter areas of mixed management need to be explored. In the National Institute of Mental Health Treatment of Depression Collaborative Research Programme over 30% of participants terminated treatment early due to adverse effects, lack of improvement or desire to change therapies. These were based on psychological and/or pharmacological treatments. Patients were obviously searching for more satisfactory treatments, non-chemical in nature and without adverse effects. An important point to note from this laser study is that the series of treatments maintained their significance for the month after completion. This suggested that follow-up or maintenance laser acupuncture sessions were important for patient well-being and the one month mark could be indicative of appropriate timing. The research team recommends larger and more specific studies to confirm these findings and explore the wider clinical implications. The team is keen to perform a multicentre study but is restricted by funding issues.

Background Depression is a serious, disabling mental disorder that severely affects quality of life. Patients with depression often do not receive adequate treatment. App-based psychotherapy is considered to have great potential to treat depression owing to its reach and easy accessibility. Objective We aim to analyze the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Methods We conducted a systematic literature review and meta-analysis. We searched Medline, Embase, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials from inception to December 23, 2020. We selected randomized controlled trials to examine the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Study selection, data extraction, and critical appraisal (using the Cochrane Risk of Bias tool for randomized studies and the ROBINS-I tool for nonrandomized studies) were conducted independently by 2 reviewers. Where possible, we pooled data using random effects meta-analyses to obtain estimates of the effect size of the intervention. We conducted post hoc meta-regression analyses to explore the factors associated with intervention success. Results After screening 3468 unique references retrieved from bibliographic searches and assessing the eligibility of 79 full texts, we identified 12 trials (2859 participants) evaluating 14 different interventions. Of 14 trials, 7 (58%) were conducted in the United States; 3 (25%) trials, in Asia (Japan, South Korea, and China); 1 (8%) trial, in Australia; and 1 (8%) trial, in Germany. Of the 12 trials, 5 (42%) trials presented a low risk of bias. The mean duration of the interventions was 6.6 (SD 2.8) weeks. Two-thirds of the interventions were based on cognitive behavioral therapy alone or included it in combination with cognitive control therapy, positive psychology, brief behavioral activation, or mindfulness- and acceptance-based therapy. With no evidence of publication bias, a pooled analysis of 83% (10/12) of the trials and 86% (12/14) of the interventions showed that app-based interventions, compared with a control group receiving usual care or minimal intervention, produced a moderate reduction in depressive symptoms (standardized mean difference [SMD] −0.51, 95% CI −0.69 to −0.33; 2018/2859, 70.58% of the participants; I2=70%). Our meta-regression analyses indicated that there was a greater reduction in symptoms of depression (P=.04) in trials that included participants with moderate to severe depression (SMD −0.67, 95% CI −0.79 to −0.55), compared with trials with participants exhibiting mild to moderate depression (SMD −0.15, 95% CI −0.43 to −0.12). Conclusions App-based interventions targeted at people with depression produce moderate reductions in the symptoms of depression. More methodologically robust trials are needed to confirm our findings, determine which intervention features are associated with greater improvements, and identify those populations most likely to benefit from this type of intervention. Trial Registration PROSPERO CRD42019145689; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=145689

The views of practising psychiatrists on treatment of the depressions were investigated as part of a Quality Assurance Project. A one in six random sample of all Australian psychiatrists was mailed a questionnaire. This asked for treatment recommendations for each of five case descriptions of patients with depression. Respondents were asked to code their treatment plans from a glossary listing possible treatments for depression: 85% of the sample responded. Tricyclic antidepressants were the treatment of choice for two cases of endogenous depression, electroconvulsive therapy (ECT) being recommended when psychotic features were present or when drug therapy had failed. Psychotherapies were the treatment of choice for cases with neurotic features, drugs being recommended when Improvement with psychotherapy did not occur.

Objective: Although the efficacy of a number of psychotherapeutic interventions has been well established in tightly controlled, randomized trials, there remains a paucity of literature examining the effectiveness of these interventions in community practice settings. In light of this, the Australian Capital Territory Mental Health Services (Canberra, ACT) set out to investigate the effectiveness of an empirically supported psychotherapeutic intervention, interpersonal psychotherapy (IPT). The present study describes a pilot evaluation of the training programme for health professionals and the IPT treatment programme. Methods: Forty community mental health professionals participated in intensive IPT training. Clinicians who completed a course of supervision were asked to apply the treatment with non-psychotic acutely depressed patients. Measures of patients’ health outcomes were taken before and after treatment using a standardized outcome measure. Results: A total of 17 out of 21 patients who were selected completed a course of 12–16 weeks of IPT. The majority of the patients had a depression originating in the post-partum period. A comparison of pre- and post-treatment scores of treatment completers revealed a significant decrease in mean depression scores. Clinicians who completed a course of training and supervision found that they were able to confidently apply IPT in a clinical setting. Conclusions: Although there were a number of barriers and obstacles to the introduction of an evidenced-based treatment, the results are promising and demonstrate that IPT can be readily taught to experienced mental health professionals. Further study is required to determine the feasibility of IPT in other non-academic settings using larger sample sizes and homogenous groups of patients.

Objectives: To study the attitudes and experiences of Australian clinicians with dissociative disorders and the paths to diagnosis and experiences of patients. Method: The attitudes of Australian clinicians to dissociative disorders and the experiences of patients were assessed by questionnaires. The clinicians were mental health specialists and a small number of general medical practitioners. The patients had all been diagnosed with a dissociative disorder. Results: Of the 250 clinicians, 21% reported experience with more than six cases on average of any one of the dissociative disorders, 38% with less than six, 42% with none; 55% regarded them as valid diagnoses, 35% dubiously valid and 10% invalid. Of the 55 patients, 76% reported delays in diagnosis (57%, <3 years and 25%, <10 years) with adverse consequences in 64%; 80% had experienced sceptical or antagonistic attitudes from clinicians, rated as destructive by 48%. They were disabled (60% rated as <50% impaired) and were heavy consumers of health services (48% hospitalized, 68% <5 times). There was considerable comorbidity including moderate or severe depression (96%), self-harm (68%), suicide attempts (69%), panic disorder (53%), eating disorders (75%), substance abuse (25%), poor physical health (44%), major interpersonal (70%) and sexual problems (90%). Patients rated individual psychotherapy as the most helpful treatment (90%) but medications, such as antidepressants, were also valued (60%). Conclusions: Although over half of the responding Australian clinicians thought that dissociative disorders were valid, the rest were dubious about their validity with 10% believing them to be invalid. Only 21% had considerable experience with the disorders. These findings may relate to some of the difficulties perceived by patients, which included delays in diagnosis, suboptimal treatment and negative experiences with clinicians.

Objective: The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. Method: MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. Results: A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and ‘goodness-of-fit’ between patients and case managers was sparse with no published Australian studies. Conclusions: The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.

Olfactory Reference syndrome (ORS) is characterized by patients falsely believing that they exude a foul body odor, which is embarrassing and disturbing to the patient. The increased anxiety due to this belief leads to compulsive behaviors, social anxiety, and functional impairment. ORS poses enormous challenges in its diagnosis and treatment. The disorder can be often treatment-resistant or recurrent. A case formulation followed by a classificatory diagnosis is an effective approach to distinguish it from other diagnoses with an overlapping spectrum of symptoms. Here, we present a case of a 42-year-old Australian woman with recurrence of ORS post major stressful triggers. She reported a trial of a series of expensive cosmetic and hydraulic treatments, however, her symptoms persisted, causing significant deterioration in her mood and social functioning, interpersonal relationships, and self-care. Patient was brought to the psychiatric inpatient unit with the complaint of feeling unsafe in her own house. She was started on Lurasidone, along with 12 weeks of intense cognitive behavioral sessions. The use of psychotherapy is underreported even though it significantly reduces ongoing distress. The patient remains asymptomatic along with improved social functioning on subsequent follow-ups.

BackgroundCannabis is the most commonly used illicit drug worldwide. Cannabis dependence is a recognised psychiatric diagnosis, often diagnosed via theDiagnostic and Statistical Manual of Mental Disorderscriteria and theInternational Classification of Diseases, 10th Revision. Cannabis use is associated with an increased risk of medical and psychological problems. This systematic review evaluates the use of a wide variety of psychological and psychosocial interventions, such as motivational interviewing (MI), cognitive–behavioural therapy (CBT) and contingency management.ObjectiveTo systematically review the clinical effectiveness of psychological and psychosocial interventions for cannabis cessation in adults who use cannabis regularly.Data sourcesStudies were identified via searches of 11 databases [MEDLINE, EMBASE, Cochrane Controlled Trials Register, Health Technology Assessment (HTA) database, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, NHS Economic Evaluation Database, PsycINFO, Web of Science Conference Proceedings Citation Index, ClinicalTrials.gov andmetaRegister of Current Controlled Trials] from inception to February 2014, searching of existing reviews and reference tracking.MethodsRandomised controlled trials (RCTs) assessing psychological or psychosocial interventions in a community setting were eligible. Risk of bias was assessed using adapted Cochrane criteria and narrative synthesis was undertaken. Outcomes included change in cannabis use, severity of cannabis dependence, motivation to change and intervention adherence.ResultsThe review included 33 RCTs conducted in various countries (mostly the USA and Australia). General population studies: 26 studies assessed the general population of cannabis users. Across six studies, CBT (4–14 sessions) significantly improved outcomes (cannabis use, severity of dependence, cannabis problems) compared with wait list post treatment, maintained at 9 months in the one study with later follow-up. Studies of briefer MI or motivational enhancement therapy (MET) (one or two sessions) gave mixed results, with some improvements over wait list, while some comparisons were not significant. Four studies comparing CBT (6–14 sessions) with MI/MET (1–4 sessions) also gave mixed results: longer courses of CBT provided some improvements over MI. In one small study, supportive–expressive dynamic psychotherapy (16 sessions) gave significant improvements over one-session MI. Courses of other types of therapy (social support group, case management) gave similar improvements to CBT based on limited data. Limited data indicated that telephone- or internet-based interventions might be effective. Contingency management (vouchers for abstinence) gave promising results in the short term; however, at later follow-ups, vouchers in combination with CBT gave better results than vouchers or CBT alone. Psychiatric population studies: seven studies assessed psychiatric populations (schizophrenia, psychosis, bipolar disorder or major depression). CBT appeared to have little effect over treatment as usual (TAU) based on four small studies with design limitations (both groups received TAU and patients were referred). Other studies reported no significant difference between types of 10-session therapy.LimitationsIncluded studies were heterogeneous, covering a wide range of interventions, comparators, populations and outcomes. The majority were considered at high risk of bias. Effect sizes were reported in different formats across studies and outcomes.ConclusionsBased on the available evidence, courses of CBT and (to a lesser extent) one or two sessions of MI improved outcomes in a self-selected population of cannabis users. There was some evidence that contingency management enhanced long-term outcomes in combination with CBT. Results of CBT for cannabis cessation in psychiatric populations were less promising, but may have been affected by provision of TAU in both groups and the referred populations. Future research should focus on the number of CBT/MI sessions required and potential clinical effectiveness and cost-effectiveness of shorter interventions. CBT plus contingency management and mutual aid therapies warrant further study. Studies should consider potential effects of recruitment methods and include inactive control groups and long-term follow-up. TAU arms in psychiatric population studies should aim not to confound the study intervention.Study registrationThis study is registered as PROSPERO CRD42014008952.FundingThe National Institute for Health Research HTA programme.

Objective: To provide a summary of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guideline for the Management of Anorexia Nervosa (AN). Conclusions: Anorexia nervosa affects only a small proportion of the Australian and New Zealand population but it is important because it is a serious and potentially life-threatening illness. Sufferers often struggle with AN for many years, if not for life, and the damage done to their minds and bodies may be irreversible. Anorexia nervosa is characterized by a deliberate loss of weight and refusal to eat. Overactivity is common. Approximately 50% of patients also use unhealthy purging and vomiting behaviours to lose weight. There are two main areas of physical interest: the undernutrition and mal-nutrition of the illness and the various detrimental weight-losing behaviours themselves. Basic psychopathology ranges from an over-valued idea of high salience concerning body shape through to total preoccupation and eventually to firmly held ideas that resemble delusions. Comorbid features are frequent, especially depression and obsessionality. It is inadvisable in clinical practice to apply too strict a definition of AN because to do so excludes patients in the early stage of the illness in whom prompt intervention is most likely to be effective. The best treatment appears to be multidimensional/multidisciplinary care, using a range of settings as required. Obviously, the medical manifestations of the illness need to be addressed and any physical harm halted and reversed. It is difficult to draw conclusions about the efficacy of further treatments. There is a paucity of clinical trials, and their quality is poor. Furthermore, the stimuli for developing AN are varied, and the psychotherapy options to address these problems need to be tailored to suit the individual patient. Because there is no known ‘chemical imbalance’ that causes the illness, no one drug offers relief. There is a high rate of relapse, and some patients are unable to recover fully. Because AN is a psychiatric illness, a psychiatrist should always be involved in its treatment. All psychiatrists should be capable of assuming this responsibility. Because cognitive behavioural methods are generally accepted as the best mode of therapy, a clinical psychologist should also be involved in treatment. Because medical manifestations are important, someone competent in general medicine should always be consulted. The optimal approach is multidisciplinary or at least multiskilled, with important contributions from psychologists, general practitioners, psychiatric nurses, paediatricians, dietitians and social workers.

Abstract Background Incident depression is associated with coronary heart disease (CHD) and increased morbidity and mortality. Treatment of depression with antidepressants and psychotherapy can be beneficial for these patients to reduce the risk of further CHD events. Ongoing management of CHD and depression mainly occurs in the community, but little is known about the identification and care of patients with comorbid CHD and depression in general practice. This study explores the prescription of antidepressants for these patients by sociodemographic variables. Methods This is an open cohort study with de-identified data based on electronic medical records of 880,900 regular patients aged 40 + years from a national general practice database in Australia (MedicineInsight). Data from 2011–2018 was used to classify patients as newly recorded CHD (CHD recorded in 2018 but not in previous years), previously recorded CHD (CHD recorded between 2011–2017) or no recorded history of CHD. Antidepressant prescribing in 2018 considered active ingredients and commercial brand names. The association between sociodemographic variables and antidepressant prescribing was tabulated according to the CHD status. Results The proportion of current depression among patients with newly recorded CHD was 11.4% (95%CI 10.3–12.6), 10.5% among those with previously recorded CHD (95%CI 10.0–11.1) and 9.6% among those with no recorded history of CHD (95%CI 9.2–10.1). Antidepressant prescribing was slightly higher among those with newly recorded CHD (76.4%; 95%CI 72.1–80.6) than among those with previously recorded CHD (71.6%; 95%CI 69.9–73.2) or no history of CHD (69.5%; 95%CI 68.6–70.4). Among males with newly recorded CHD and depression, antidepressant prescribing was more frequent in major cities or inner regional areas (~ 81%) than in outer/remote Australia (66.6%; 95% CI 52.8–80.4%). Conclusions Although antidepressant prescribing was slightly greater in those with newly recorded CHD compared to those with depression alone, its clinical significance is uncertain. Much larger differences in prescribing were seen by geographic location and could be addressed by innovations in clinical practice.

Objective: It has been widely predicted that the COVID-19 pandemic will have a detrimental impact on the mental health (MH) of individuals. This has been dubbed as the MH ‘second wave’. In Australia, these impacts have been partly mitigated by institutional responses such as increased access to psychotherapy. Consultation Liaison (CL) psychiatry services provide MH care to acutely unwell patients in general hospitals. It was hypothesised that the number of referrals to the studied service had increased since the start of the pandemic. Methods: From the Electronic medical records (eMRs), the authors collected daily referral numbers, over 3 consecutive years, to a large CL service in metropolitan Sydney. Results: Referrals were significantly increased by 25%, 95% CI [1.14, 1.36], p < .001 since the start of the pandemic. This increase was delayed, and remained elevated despite a reduction in COVID-19 infections. Conclusion: This study adds evidence to the existence of the MH ‘second wave’, highlights a key impact on healthcare workers’ well-being and will assist in guiding resource allocation decisions in the near future.

Mindfulness-based interventions (MBI) represent a central pillar of the third wave of Cognitive Behavioral Therapy. In recent years, MBI have been implemented in treating patients with psychotic disorders, and their efficacy has been evaluated in a small number of randomized-controlled trials (RCTs). This narrative review presents the current state of research on the efficacy and effectiveness, as well as central aspects of the clinical applications of MBI in the treatment of patients with schizophrenia and primary psychotic disorders. Current meta-analyses show different results but concur that in comparison to controls with treatment-as-usual (TAU) and in Pre-Post-Analyses, MBI show promising results in reducing the, in regards to pharmacotherapy, difficult to treat negative (<i>g</i> = 0.56 and <i>g</i> = 0.75) and positive symptoms (<i>g</i> = 0.19 and <i>g</i> = 0.32) with effect sizes between small and large. In addition, MBI can lead to positive effects on depressive and anxiety symptoms (<i>g</i> = 0.20 and <i>g</i> = 0.43) and contribute to a long-term reduction in re-hospitalization rates 12 months post-discharge and a shortening of the duration of inpatient treatment. In contrast to psychotherapy research from the UK, Australia, and Hong Kong, the scientific evaluation and implementation of mindfulness-based treatment options in the entire German-speaking area are still in the early stages.

IntroductionA catastrophe is often considered to be a final decisive event, resulting in a disastrous end. Two recent examples of catastrophes satisfying this definition were the 2012 super storm Sandy in the United States of America and the 2011 floods in Brisbane, Australia. The progress of these disasters was reported worldwide, yet coverage soon disappeared from the headlines, leaving people to deal with the aftermath of rebuilding homes, businesses and lives. The diagnosis of breast cancer is an individual’s catastrophic event. While not on the community-wide scale of the disasters mentioned previously, it can have disastrous effects on the individual as well as their family and friends. At the moment 1 in 8 women can expect to have a breast cancer diagnosis. In Australia alone this means approximately 1,375,000 people are likely to receive this diagnosis in the course of their lifetime. This article addresses how breast cancer can and does prompt women and their supportive friends, families and partners to become more creative as a result of the breast cancer (BC) diagnosis. In these cases, creativity—defined as doing something a little differently or thinking outside the square—can offer some remedy for catastrophe. Becoming totally involved in the creative moment, so as to lose all track of time and forget the trials and worries of BC, is referred to as flow. Flow is an “optimal experience” in which “people become so involved in what they are doing that the activity becomes spontaneous, almost automatic; they stop being aware of themselves as separate from the actions they are performing” (Csikszentmihalyi 53). This is one fruit of the creative process. This article refers to women as having breast cancer because the majority of people diagnosed with BC are women. However it is acknowledged that men constitute 0.8% of the total number of people diagnosed with BC (Breast Cancer in Australia). Responding to public concern, a range of charities has been formed to support people with breast cancer. One such charity is Breast Cancer Care WA (BCCWA). Together with the Australian Research Council (ARC) and Edith Cowan University (ECU), BCCWA supports an online community for people with breast cancer, Breast Cancer Click (Click). The membership of Click includes several male Clickers who are partners and supporters of Click members with BC. The Click online community consists of people with BC and their supporters, as well as health care practitioners and researchers. Those members with breast cancer are very interested in learning more about BC and supporting others in a similar situation whereas the health care practitioners and researchers are both supporting those with breast cancer and exploring the possibilities offered by online communities, to enhance their professional skills. Members of Click could be described as a community of practice, “groups of people informally bound together by shared expertise and passion for a joint enterprise” (Wenger and Snyder 139), in this case a passion for responding positively to a BC diagnosis. Wenger and Snyder go on to say: “People in communities of practice share their experiences and knowledge in free-flowing, creative ways that foster new approaches to problems” (140). The Click community helps foster creativity.Many of the verbatim quotes used in this article are taken from the www.breastcancerclick.com.au (Click) website. Instead of identifying a speaker with a personal attribution the term “Clicker” is used, and then qualified as a Clicker with breast cancer (BC) to differentiate the author from a Clicker who supports someone with breast cancer (Supporter). The Click website provides every member with an opportunity to express themselves and they often respond creatively to the challenges that confront them. The Chaos and Catastrophe of a Breast Cancer Diagnosis When a woman is first diagnosed with breast cancer, it is often as a result of her bi-annual mammogram. She expects a routine visit but is advised instead that she requires further investigation because abnormalities have been detected. This is not what she expected. Probably all previous mammograms have been normal. The personal catastrophe occurs when the woman receives a definitive diagnosis of breast cancer. Chaos is added to catastrophe as the patient and her family struggle to grasp the meaning of the diagnosis and the multiplicity of treatment options. For some, the diagnosis is quickly followed by another catastrophic event, the removal of one or both breasts. For others the catastrophe occurs by increments. This is evident in a member’s blog on the Click website,More surgery [...] dammit!!!!!!!!!! I just want this over NOW. The whole lot. I want my hair back, I want my working life back, I want the smile back on my man's face. I want ME back. I want to dance again. I want to have a conversation with friends that doesn't include my diagnosis or prognosis [...] short term, long term [...] any bloody term!!!! (Clicker BC) People with a breast cancer diagnosis do not always have an endpoint in sight, or an acceptable endpoint at all, and the chaos of treatment and recovery is focused on coping with the present and the next treatment on the horizon. This Clicker uses her blog to help her deal with the next stage of a seemingly interminable round of surgical and chemotherapeutic procedures which have thrown herself, her family, her friends and her work life into chaos. Other Clickers immediately responded to her angst with messages of support and understanding. Had this clicker not written a blog, she would not have received this support and consequently she may have coped less successfully with her treatment. Given the chaos and catastrophe inherent in a breast cancer diagnosis, what else can individuals do that makes a positive difference to their lives as they deal with the “treatment, wait, check” cycle that is the medical response to breast cancer? Creativity Arising from Chaos When people receive a life threatening diagnosis such as breast cancer, they sometimes choose to think outside the square, to do things a little differently, to change the way they relate to others, to learn a new art or craft or to take up a musical instrument. Being creative seems to provide distraction from the treatment, and may be something to look forward to when the treatment is over. Some choose to participate in a formal creative therapy program, others seek out a creative pursuit which they can do at home. For some women with a breast cancer diagnosis, joining the Click website is itself a creative act. Contributing to an online community with a common interest in BC which gives them unconditional support, such as Click, also provides them with new skills and allows other people to benefit from their advice and experience: Hi everyone. I know we all have different ways of dealing with our cancer. Mine has been to be more mindful of the wonders around me and savour every possible moment of joy. I have decided to start my own Blog to give myself a creative outlet and share my experiences. (Clicker BC) There may be a number of reasons for participating in an online community of people with breast cancer and their supporters. Whatever the motivation, it requires a person to think laterally and learn new skills in how to navigate and post to a website. A newbie member enters a relationship with people she hasn’t met. She can choose to create a new persona using an avatar, or simply devise a username which represents her online. Creativity, Click and Flow Susan Nesbit, an Associate Professor in the University of Manitoba’s occupational therapy department, was diagnosed with BC in 2000. She used “everyday creativity to maintain a good attitude and positive spirits” and refers to Csikszentmihalyi’s concept of “flow” to explain the gratifying experience which occurs when someone fully participates in an activity:that I am doing it for its own sake, and when I become so involved […] that I become spontaneous and almost automatic, I am experiencing flow. My energy flows smoothly, I feel relaxed, comfortable, energetic and totally absorbed, losing track of time. (Nesbit 63) Richards (489) describes creativity as having two conditions: one is originality and the other is meaningfulness. She argues that everyday creativity “in the multitudinous activities of day-to-day life […] has been conceptualised as a survival capability” (489). Click allows members to share this everyday creativity, inspiring a creative response in others. One Clicker (BC), who produces handmade cards at home, was inspired to hold a Skype card-making education session for rural and remote people (with and without BC).Today is a day of craft for me. I held my first remote workshop […] and it was a huge success. Just made a couple of Father's Day cards for a customer and decided to share some of my work with you all. I'd love you to take a peek at my album [...] doing what I love to do was and is my therapy to get me through each new crisis xxx. (Clicker BC) It seems this Clicker first achieved flow through the act of making cards for her own pleasure and then maintained that flow through the planning and execution of an online card making class, which was a great success. She found something that helped her to take control of her life and to live more fully and at the same time gave others the opportunity to do the same. The success of this session might inspire this Clicker to conduct more sessions for others, while those attending the session who may be battling a serious illness, might also achieve flow through absorption in the card-making process, then maintain flow through the positive responses they receive from recipients of these cards. Ripples in this online creative space reach out towards a widening pool of card makers, assisting them to cope with chaotic occurrences. Creative Therapy and Breast Cancer Some women may choose to participate in formal creative therapy programmes such as art therapy to help them deal with their cancer treatment. In general more women than men with cancer choose to use this creative response to help them cope (Geue et al. 168). This intervention when used with breast cancer patients has been shown to enhance psychological well-being by decreasing negative emotional states and enhancing positive ones (Puig et al. 224). For example, music therapy with a group of BC patients waiting for a chemotherapy cycle appeared to directly reduce patients’ anxiety and physiological arousal, while enhancing their sense of wellbeing and control (Bulfone et al. 241). Blogging and Breast Cancer The creative pursuit may already be part of woman’s “normal” or pre-diagnosis life, or may be identified and pursued as a result of the diagnosis and used as informal therapy to keep the chaos at bay, for example through joining a support website and blogging. Orgad’s research shows that when women write about their breast cancer story, “storytelling” online, it helps them cope with their disease. “The act of writing is seen as a crucial affirmation of living, a statement against fearfulness, invisibility and silence” (Lord qtd in. Orgad 67). The new ideas and direction for these women’s creativity may also be used to vent their feelings and to gain perspective on their breast cancer journey, or the story may be written to help others facing a similar journey. As evidenced by the collection of blogs at breastcancerblogs.org it seems a number of women find blogs offer a creative response to their breast cancer journey. The BC blogosphere is a vibrant record of resistance to the disease. Click members are encouraged to blog, and are given space on the site to do so, with full privacy if they choose. A study conducted by Chung and Kim (304) showed those cancer patients and their companions found blogging activity to be helpful in emotion management and for information sharing. The Clickers are also encouraged to complete a SWEE in their blog. SWEE stands for “structured written emotional expression” where a person writes about their breast cancer journey for 10-15 minutes each day for three to five days in a row. The Clicker has the opportunity to creatively express their positive and negative feelings about their breast cancer diagnosis. Research shows that writing a SWEE can be good for both physical and emotional health (Pennebaker 540; Lieberman, Morton and Goldstein 859; Butcher and Buckwalter 114; Stanton et al. 4165; Low, Stanton and Danoff-Burg 187). One Click member, the author of the Paw Paw Salad blog, received a top blog award from the breastcancerblogs website. She writes about her life with breast cancer and the stress of not knowing when or if she will ever be free of the disease. She is positive, however, about the Tamoxifen tablet she must take for another five years or more. She tries to only let the word “cancer” briefly enter her mind, once a day, when she takes her pill and to carry on as normal the rest of the time. On returning home from a camping trip, which she also described in her blog, she noted that her cancer medication bottle was looking battered and dirty.And for the first time, the sight of it made me smile. I've decided that this is just the way my Tamoxifen bottle should look. It’s not a bottle to be kept pristine in a medicine cabinet—I want it to be tossed into suitcases, kept cold in dust-covered eskies, dropped on the floor in the morning flurry. I'm hoping that my daily reminder of cancer will, as often as possible, be washed down with camp-stove coffee. And I’m thinking that the last pill of each year’s prescription demands a champagne and strawberry chaser (Paw Paw Salad). This post demonstrates the blogger’s ability to perceive and describe BC paraphernalia differently, and she uses this perspective to bolster her resilience in the face of the ongoing BC chaos in her life. Some Clickers express ambivalence towards taking Tamoxifen, a hormone based chemotherapeutic agent, because of its potentially deleterious side effects on their everyday sense of wellbeing. This blog entry may give them a new perspective on life, in spite of the possible side effects of the drug, and encourage them to celebrate the end of each year of taking the pill as one step towards being free of cancer. The fact that the writer can go camping while taking the Tamoxifen pill also demonstrates to others that life doesn’t have to stop. Mammoirs Some people with a BC diagnosis (non-Click members) have gone on to write what is affectionately called a “mammoir” a book which recounts their breast cancer journey or provides advice and information for those newly diagnosed with breast cancer. This is the term applied by Clickers even to established works of literature, such as Professor Brenda Walker’s award-winning “mammoir,” Reading by Moonlight: How Books Saved a Life. The book describes how Walker took refuge from the chaos of her breast cancer diagnosis in the books she’d always loved. Her experience of chaos prompted her to turn towards the creativity of others, which in turn triggered renewed creativity in the form of her memoir. Conclusion A diagnosis of breast cancer is for most women, a catastrophe. The newly diagnosed person is aware that this diagnosis may well be followed quite quickly by a mastectomy. Together with adjunct treatments, such as chemotherapy and/or radiotherapy, this causes chaos within the woman’s life, family and friendship networks. Each woman and her supporters deal with the catastrophe and ensuing chaos in their own individual creative way. Creative expressions include blogs, where women can tell their story; poetry, such as haikus and free verse; and simple venting of feelings about diagnosis and treatment. The SWEE technique seems to indicate that written engagement helps people cope with their diagnosis and illness. Attendance at art or music therapy sessions has been shown to be therapeutic and “mammoirs” have been written to help others to avoid the pitfalls of the health system or to deal with treatment and its side-effects. Both informal and formal or organised creative therapy appears to have positive psychological effects on the woman with breast cancer. Whether each individual with BC achieved flow, as described by Csikszentmihalyi, is not known, but it appears from the Click community that many do use everyday creative acts to help them deal with the ongoing chaos of their diagnosis and treatment. The Click was created to provide a blank canvas for those with breast cancer and their supporters to reach out to others in a similar situation. Through allowing people to respond creatively and to have those creative responses validated, this reaching out often also involves reaching in—and harnessing creativity. ReferencesAustralian Institute of Health and Welfare and Cancer Australia, 2012, Breast Cancer in Australia: An Overview, Cancer Series 71. CAN 67. Canberra: AIHW.Blog Nation. “breastcancerblogs.org.”2011-2012. 11 Mar. 2013 ‹http://www.breastcancerblogs.org/›. Breast Cancer Click. Breast Cancer Care WA. 2013. 6 Mar. 2013 ‹http://www.breastcancerclick.com.au›. Bulfone, Teresa, et al. "Effectiveness of Music Therapy for Anxiety Reduction in Women with Breast Cancer in Chemotherapy Treatment." Holistic Nursing Practice 23.4 (2009): 238-242. Butcher, Howard Karl, and K. Buckwalter. "Exasperations as Blessings: Meaning-Making and the Caregiving Experience." Journal of Aging and Identity 7.2 (2002): 113-132. Chung, Deborah S., and Sujin Kim. "Blogging Activity among Cancer Patients and Their Companions: Uses, Gratifications, and Predictors of Outcomes." Journal of the American Society for Information Science and Technology 59.2 (2007): 297-306. Csikszentmihalyi, Mihaly. Flow: The Psychology of Optimal Experience. New York: Harper and Row, 1990. Geue, Kristina, et al. "An Overview of Art Therapy Interventions for Cancer Patients and the Results of Research." Complementary Therapies in Medicine 18.3 (2010): 160-170. Lieberman, Morton A., and Benjamin A. Goldstein. "Self-Help On-Line: An Outcome Evaluation of Breast Cancer Bulletin Boards." Journal of Health Psychology 10.6 (2005): 855-862. Low, Carissa A., Annette L. Stanton, and Sharon Danoff-Burg. "Expressive Disclosure and Benefit Finding among Breast Cancer Patients: Mechanisms for Positive Health Effects." Health Psychology 25.2 (2006): 181-89. Nesbit, Susan G. "Using Creativity to Experience Flow on My Journey with Breast Cancer." Occupational Therapy in Mental Health 22.2 (2006): 61-79. Orgad, Shani. Storytelling Online: Talking Breast Cancer on the Internet. NY: Peter Lang, 2005. “Jagged Little Pill.” Paw Paw Salad. 16 Oct. 2012. 11 Mar. 2013. ‹http://www.paw-paw-salad.com/›. Pennebaker, J. "Putting Stress into Words: Health, Linguistic, and Therapeutic Implications." Behaviour Research and Therapy 31.6 (1993): 539-548. Puig, Ana, et al. "The Efficacy of Creative Arts Therapies to Enhance Emotional Expression, Spirituality, and Psychological Well-Being of Newly Diagnosed Stage I and Stage II Breast Cancer Patients: A Preliminary Study." The Arts in Psychotherapy 33.3 (2006): 218-228. Richards, Ruth. “When Illness Yields Creativity.” Eminent Creativity, Everyday Creativity and Health. Eds. Mark Runco and Ruth Richards. Greenwich: Ablex, 1997. 485-540. Stanton, Annette L, et al. "Randomized, Controlled Trial of Written Emotional Expression and Benefit Finding in Breast Cancer Patients." Journal of Clinical Oncology 20.20 (2002): 4160-4168. Wenger, Etienne, and William Snyder. "Communities of Practice: The Organizational Frontier.” Harvard Business Review 78.1 (2000): 139-146. Walker, Brenda. Reading by Moonlight: How Books Saved a Life. Australia: Penguin, 2010. Acknowledgements A special thanks to all the people, women and men, who have shared their lives with the research team via the Breast Cancer Click website. Breast Cancer Care WA, our ARC Linkage Project industry partner.

Scenario: You are exhausted after a long day at work and collapse in front of the television for some mindless entertainment. One of your favourite comedy shows is on. You begin to relax. You laugh a couple of times. There's a commercial break. You watch the first ad for a hardware store, giving it only half your attention. And then there's another ad, something about a father and son in a car together and then ". WOOOMPH! A truck slams into the car. The message is "Speed kills!" Or there are people playing and sunbathing on a beach, happy holidays, and then vultures descend and surround them. The message is "Slip! Slop! Slap! Don't die in the sun this summer". Or someone is shown smoking a cigarette and the caption reads : "Give up now. You'll soon stop dying for a cigarette". This might be accompanied by scenes of a post-mortem, dissections of human lungs or brain. Context Threat appeals are used frequently in health and road safety promotion. Many use the threat of death as the consequence of undesirable behaviours, for example, "Quit smoking or you'll die' (Henley and Donovan). ("Non-death threats' appeal to other consequences such as "Quit smoking or your skin will age'.) There is an implicit notion of premature death threat, although this is rarely stated explicitly. When reminded of our risk of premature death, we are reminded by extension of the ultimate inevitability of our death. An understanding of the philosophy of existentialism can help us understand why consumers may, quite reasonably, tune out, or literally switch off health promotion messages that remind them of their own death. This paper explores the effect on consumers of these mass media invocations of the fear of death, or "death threats'. Verbatim comments are included from six focus groups conducted on fear and health promotion. Groups were delineated by age (16-20 years, 21-29 years and 30-49 years), gender, and socio-economic status (blue collar/white collar) (Henley). What is existential dread? Fear is one of the primary human emotions (along with anger, sadness, love, joy and surprise) and "dread' is one of the emotion names associated with fear (Shaver et al. 1067). We do not need to learn how to feel fear. We have to learn what to fear, however. Despite the joke about death and taxes, death is uniquely inevitable. (Some people do manage to avoid taxes!) In his definitive work, Denial of Death, Becker stated his belief that knowledge of our own death is the source of 'man's peculiar and greatest anxiety' (70); it's what makes us human. Existentialists think that knowing about the inevitability of our own death can be overwhelming, arousing the worst fear imaginable, "existential dread' (Bugental 287). Existential philosophers and psychologists believe that part of this anxiety stems from the existential dread of "not being'. Discussing Heidegger's analysis of the meaning of death in Being and Time, Barrett put it this way: The point is that I may die at any moment, and therefore death is my possibility now. It is like a precipice at my feet. It is also the most extreme and absolute of my possibilities: extreme, because it is the possibility of not being and hence cuts off all other possibilities; absolute, because man can surmount all other heartbreaks, even the deaths of those he loves, but his own death puts an end to him (201). The essence of existential philosophy is this idea that we are all deeply, terribly afraid of death. Fear of death can be seen even in very young children (Anthony, The child's; Anthony, The discovery; Nagy) who express considerable anxiety about death, but quickly learn from their parents and others how to deny it (Yalom). Existential psychologists have suggested that the fear of our own death is the cause of much of our psychopathology (Yalom). Existentialists believe that the most common response to existential anxiety is to deny it, creating in oneself a 'state of forgetfulness of being' as far as possible. Weisman described three levels of denial in terminally ill patients: "first-order denial' of the facts of illness; "second-order denial' of the implications of the illness; and "third-order denial' of death itself. He noted that often a patient moves from first and second order denial into "middle knowledge' (i.e., acceptance of near death), but then relapses. Weisman remarked that this relapse is often the signal that the terminal phase has begun. This aspect of denial is a complicated factor in the complex measurement of death anxiety. When people say they are not afraid of death, who can say whether they are denying fear or truly not afraid? In either case, health promotion appeals that threaten death may not be effective, either because the fear is denied or because there is no fear. In focus groups exploring people's concepts of death (Henley 111), few people acknowledged being afraid of their own death and many specifically stated that they were not afraid of their own death. One woman voiced the universal difficulty of truly conceiving what it might be like "not to be' (Kastenbaum and Aisenberg) when she said: 'death seems like such an unrealistic proposition'. People did acknowledge fears about death, such as dying painfully, so health promotion messages that threaten these other dimensions of death anxiety may be more effective. Health promotion practitioners frequently use these related death fears. The fear of causing death, for example, is used in road safety advertisements. However, this discussion on existential fear is limited to threat appeals of death per se. Death threats in health promotion Is arousing existential dread an effective way to market healthy behaviours? At first sight, it seems logical that the threat of death would be more persuasive than lesser threats and yet it may not be the most effective approach. There is some evidence that lesser threats may be more effective for some groups of adolescents and young adults for smoking (Donovan and Leivers), and for road safety behaviours (Donovan et al.). For example, for some 18 year old males, the threat of being caught drinking and driving, of losing their driving licence and, thus, their new-found independence may be a more effective deterrent than the threat of dying in a car accident (Donovan et al.). The humiliation of being arrested and charged for drink-driving may be the most powerful persuader for adults of all ages (Bevins). For men attending the Jerusalem Centre for Impotency and Fertility, impotence was reported a more persuasive threat than death: 78% of men who were told that smoking causes impotence quit smoking, compared to 40% who quit when told that smoking causes heart attacks ("No smoking tip"). One woman in a focus group said, 'you tend to think short-term, "can I afford a $100 fine?" rather than long-term, "this is my life." If I stop to think about it, obviously I'm more afraid of dying than $100 [fine], but that's not what I think about' (Henley 95). This makes sense in the context of forgetfulness, the denial of death. We don't want to be reminded of our death so we switch off the death message. Lesser threats may be more easily internalised. Does arousing existential dread do any harm? Perhaps. Job suggested that fear arousal is likely to be effective only for specific behaviours that successfully reduce the level of fear arousal and that high-fear messages may actually increase behaviours that people employ to reduce anxiety, such as smoking and alcohol consumption. People high in anxiety are hypothesised to be hypersensitive to threats and likely to employ a restricted range of self-soothing coping behaviours to reduce negative affect (Wickramasekera and Price). Death threat appeals such as "Quit smoking or you'll die' may arouse defensive, counter-productive responses, at least in some people, because it is impossible to identify any specific behaviour that could successfully reduce the particular, unique fear of death per se. Firestone identified a number of psychological defences against death anxiety, including self-nourishing and addictive habits, such as smoking and overeating. Ironically, these same behaviours are frequently the subject of health promotion campaigns. If such campaigns arouse death anxiety in an effort to curb defensive responses to death anxiety, there clearly could be an increase rather than a decrease in those defensive responses. Arousing death anxiety might contribute to fatalistic thinking. Job described some people's defenses against very high fear, for example, "...you've got to go sometime' or "...when your number's up, your number's up'. In focus groups, people commented, 'if an accident is going to happen, it's going to happen' and 'what's the point of giving up [unhealthy behaviours] if you get run over by a bus tomorrow?' (Henley 95, 108). Rippetoe and Rogers found that fatalistic thinking occurred when subjects did not believe that the recommended behaviour would avert the threat. That is, people may realise that quitting smoking could avert lung cancer and even some causes of premature death but that nothing can avert death itself. Fatalism may be one of the most maladaptive responses because the threat is acknowledged but rendered ineffective (Rippetoe and Rogers). Social marketers can make some of their persuasive communications more effective if they are more mindful of consumers' existential fears. A sensitivity to consumers' psychological defences against existential fear may result in more effective use of threat appeals in health promotion. Mindfulness Mindful that the title of this paper itself may arouse some existential dread, I end with a comment on the existentialist alternative to denial. Existentialists advocate a state of 'mindfulness of being' or 'ontological mode' (Heidegger, quoted in Yalom 31) in which "one remains mindful of being, not only mindful of the fragility of being but mindful, too ... of one's responsibility for one's own being." (Yalom 31). The existentialist strives to be as mindful, as present in the moment, and therefore as authentic as possible. This involves the acceptance of existential anxiety as an appropriate and reasonable response to the human condition (Bugental). Some focus group participants wanted to know in advance that they were going to die, 'so you can fit things in you'd want to do and say goodbye'. Others thought it was better not to know or 'you'd start having regrets'. One person pointed out that we do know in advance: 'you know you're going to die sometime!'. This last comment was followed by a sober, almost shocked silence suggesting that, even while we are freely discussing death on one level, the full meaning of death may still elude us. As consumers of health promotion messages, we are exposed to many reminders of our finite existence. If we sit mindlessly in front of the television receiving these messages, we may feel some unresolved discomfort. People talk about looking away, or switching channels when particularly shocking ads are shown. The existentialist alternative response would be to embrace these reminders and use them to sustain a state of mindfulness. With this state of mindfulness comes a heightened sense of responsibility for one's own being. It is in this ontological mode that we are most likely to adopt the healthy behaviours recommended in health promotion messages. By hearing the death threat openly, and acting to protect ourselves from at least those causes of premature death that may lie within our control, we may be able to discover a fuller experience of what it means to be alive. References Anthony, Sylvia. The Child's Discovery of Death. New York: Harcourt, Brace & World, 1940. Anthony, Sylvia. The Discovery of Death in Childhood and After. Harmondsworth, Middlesex: Penguin Education, 1973. Barrett, W. Irrational Man, A Study in Existential Philosophy. London: Heinemann, 1958. Becker, Ernest. The Denial of Death. New York: The Free Press, 1973. Bevins, John. "Using Advertising to Sell and Promote Health and Healthy Products". Paper presented at the ACHPER Health Products and Services Marketing Seminar. Kuring-gai College, Sydney, 1987. Bugental, J. F. T. The Search for Authenticity: An Existential-analytic Approach to Psychotherapy. New York: Holt, Rinehart and Winston, Inc., 1965. Donovan, Robert J., and Sue Leivers. Young Women and Smoking. Report to Commonwealth Department of Human Services and Health. Perth: Donovan Research, 1988. Donovan, Robert J., Nadine Henley, Geoffrey Jalleh, and Clive Slater. Road Safety Advertising: An Empirical Study and Literature Review. Canberra: Federal Office of Road Safety, 1995. Firestone, Robert W. "Psychological Defenses against Death Anxiety." Death Anxiety Handbook: Research, Instrumentation, and Application. Series in Death Education, Aging, and Health Care. Ed. Robert A. Neimeyer. Washington, DC: Taylor & Francis, 1994. 217-241. Henley, Nadine R. "Fear Arousal in Social Marketing: Death vs Non-death Threats." Doctoral Dissertation, University of Western Australia, Perth, 1997. Henley, Nadine and Robert J. Donovan. "Threat Appeals in Social Marketing: Death as a "Special Case'". International Journal of Nonprofit and Voluntary Sector Marketing, 4.4 (1999): 300-319. Job, R. F. Soames. "Effective and Ineffective Use of Fear in Health Promotion Campaigns." American Journal of Public Health, 78 (1988): 163-167. Kastenbaum, R., and R. Aisenberg. The Psychology of Death. London: Duckworth, 1974. Nagy, Maria H. "The Child's View of Death." The Meaning of Death. Ed. Herman Feifel. New York: McGraw-Hill Book Company, 1959. 79-98. "No Smoking Tip for Lovers". Daily Telegraph, (1994, September 24): p. 4. Rippetoe, P.A. and Rogers, R.W. "Effects of components of protection-motivation theory on adaptive and maladaptive coping with a health threat." Journal of Personality and Social Psychology, 52.3 (1987): 596-604. Shaver, P., J. Schwartz, D. Kirson, and C. O'Connor. "Emotion Knowledge: Further Exploration of a Prototype Approach." Journal of Personality and Social Psychology, 52.6 (1987): 1061-1086. Weisman, A.D. On dying and denying: A psychiatric study of terminality. New York: Behavioral Publications, 1972. Wickramasekera, Ian and Daniel C. Price. "Morbid Obesity, Absorption, Neuroticism, and the High Risk Model of Threat Perception." American Journal of Clinical Hypnosis, 39 (1997): 291-301. Yalom, I. D. Existential Psychotherapy. New York: Basic Books, 1980. Citation reference for this article MLA Style Henley, Nadine. "You will die! " M/C: A Journal of Media and Culture 5.1 (2002). [your date of access] < http://www.media-culture.org.au/0203/youwilldie.php>. Chicago Style Henley, Nadine, "You will die! " M/C: A Journal of Media and Culture 5, no. 1 (2002), < http://www.media-culture.org.au/0203/youwilldie.php> ([your date of access]). APA Style Henley, Nadine. (2002) You will die! . M/C: A Journal of Media and Culture 5(1). < http://www.media-culture.org.au/0203/youwilldie.php> ([your date of access]).

IntroductionThis article addresses the experience of designing and conducting life-writing workshops for a group of clients with severe mental illness; the aim of this pilot study was to begin to determine whether such writing about the self can aid in individual ‘recovery’, as that term is understood by contemporary health professionals. A considerable amount has been written about the potential of creative writing in mental health therapy; the authors of this article provide a brief summary of that literature, then of the concept of ‘recovery’ in a psychology and arts therapy context. There follows a first-hand account by one of the authors of being an arts therapy workshop facilitator in the role of a creative practitioner. This occurred in consultation with, and monitored by, experienced mental health professionals. Life-Writing as ‘Therapeutic’ Life-story or life-writing can be understood in this context as involving more than disclosure or oral expression of a subject’s ‘story’ as in psycho-therapy – life-story is understood as a written, structured narrative. In 2001, Wright and Chung published a review of the literature in which they claimed that writing therapy had been “restimulated by the development of narrative approaches” (278). Pennebaker argues that “catharsis or the venting of emotions” without “cognitive processing” has little therapeutic value and people need to “build a coherent narrative that explains some past experience” in order to benefit from writing” (Pennebaker, Telling Stories 10–11). It is claimed in the Clinical Psychology Review that life-writing has the therapeutic benefits of, for example, “striking physical health and behaviour change” (Esterling et al. 84). The reasons are still unclear, but it is possible that the cognitive and linguistic processing of problematic life-events through narrative writing may help the subject assimilate such problems (Alschuler 113–17). As Pennebaker and Seagal argue in the Journal of Clinical Psychology, the life-writing processallows one to organise and remember events in a coherent fashion while integrating thoughts and feelings ... This gives individuals a sense of predictability and control over their lives. Once an experience has structure and meaning, it would follow that the emotional effects of that experience are more manageable. (1243)It would seem reasonable to suggest that life-writing which constructs a positive recovery narrative can have a positive therapeutic effect, providing a sense of agency, connectedness and creativity, in a similar, integrating manner. Humans typically see their lives as stories. Paul Eakin stresses the link between narrative and identity in both this internal life-story and in outwardly constructed autobiography:narrative is not merely a literary form but a mode of phenomenological and cognitive self-experience, while self – the self of autobiographical discourse - does not necessarily precede its constitution in narrative. (Making Selves 100)So both a self-in-time and a socially viable identity may depend on such narrative. The term ‘dysnarrativia’ has been coined to describe the documented inability to construct self-narrative by those suffering amnesia, autism, severe child abuse or brain damage. The lack of ability to achieve narrative construction seems to be correlated with identity disorders (Eakin, Fictions in Autobiography 124). (For an overview of the current literature on creative and life-writing as therapy see Murphy & Neilsen). What is of particular relevance to university creative writing practitioners/teachers is that there is evidence, for example from Harvard psychiatrist Judith Herman and creative writing academic Vicki Linder, that life-narratives are more therapeutically effective if guided to be written according to fundamental ‘effective writing’ aesthetic conventions – such as having a regard to coherent structure in the narrative, the avoidance of cliché, practising the ‘demonstrate don’t state’ dictum, and writing in one’s own voice, for example. Defining ‘Recovery’There remains debate as to the meaning of recovery in the context of mental health service delivery, but there is agreement that recovery entails significantly more than symptom remission or functional improvement (Liberman & Kopelowicz). In a National Consensus Statement, the Substance Abuse and Mental Health Services Administration (SAMHSA) unit of the US Department of Health and Human Services in 2005 described recovery (in general terms) as being achieved by the enabling of a person with a mental illness to live meaningfully in a chosen community, while also attempting to realize individual potential. ‘Recovery’ as a central concept behind rehabilitation can be understood both as objective recovery – that is, in terms of noting a reduction in objective indicators of illness and disability (such as rates of hospital usage or unemployment) and a greater degree of social functioning – and also as subjective recovery. Subjective recovery can be ascertained by listening closely to what clients themselves have said about their own experiences. It has been pointed out (King, Lloyd & Meehan 2) that there is not always a correspondence between objective indicators of recovery and the subjective, lived experience of recovery. The experience of mental illness is not just one of symptoms and disability but equally importantly one of major challenge to sense of self. Equally, recovery from mental illness is experienced not just in terms of symptoms and disability but also as a recovery of sense of self … Recovery of sense of self and recovery with respect to symptoms and disability may not correspond. (King, Lloyd & Meehan; see also Davidson & Strauss)Symptoms of disability can persist, but a person can have a much stronger sense of self or empowerment – that is still recovery. Illness dislocates the sense of self as part of a community and of a self with skills and abilities. Restoring this sense of empowerment is an aim of arts therapy. To put it another way, recovery is a complex process by which a client with a mental illness develops a sense of identity and agency as a citizen, as distinct from identification with illness and disability and passivity as a ‘patient’. The creative arts have gone well beyond being seen as a diversion for the mentally ill. In a comprehensive UK study of creative arts projects for clients with mental illness, Helen Spandler et al. discovered strong evidence that participation in creative activity promoted a sense of purpose and meaning, and assisted in “rediscovering or rebuilding an identity within and beyond that of someone with mental health difficulties” (795). Recovery is aided by people being motivated to achieve self-confidence through mastery and competence; by learning and achieving goals. Clearly this is where arts therapy could be expected or hoped to be effective. The aim of the pilot study was not to measure ‘creativity’, but whether involvement in what is commonly understood as a creative process (life-writing) can have flow-on benefits in terms of the illness of the workshop participant. The psychologists involved, though more familiar with visual arts therapy (reasonably well-established in Australia – in 2006, the ANZAT began publishing the Australian and New Zealand Journal of Art Therapy), thought creative writing could also be valuable. Preparation for and Delivery of the Workshops I was acutely aware that I had no formal training in delivering a program to clients with mental health illness. I was counselled during several meetings with experienced psychologists and a social worker that the participants in the three workshops over two weeks would largely be people who had degrees of difficulty in living independently, and could well have perceptual problems, could misjudge signals from outside and inside the group, and be on medication that could affect their degree of engagement. Some clients could have impaired concentration and cognition, and a deficit in volition. Participants needed to be free to leave and rejoin the workshops during the afternoon sessions. Attendance might well fall as the workshops progressed. Full ethical clearance was attained though the University of Queensland medical faculty (after detailed description of the content and conduct of the proposed workshops) and consent forms prepared for participants. My original workshop ‘kit’ to be distributed to participants underwent some significant changes as I was counselled and prepared for the workshops. The major adjustment to my usual choice of material and approach was made in view of the advice that recounting traumatic events can have a negative effect on some patients – at least in the short term. For the sake of both the individuals and the group as a whole this was to be avoided. I changed my initial emphasis on encouraging participants to recount their traumatic experiences in a cathartic way (as suggested by the narrative psychology literature), to encouraging them to recount positive narratives from their lives – narratives of ‘recovery’ – as I explain in more detail below. I was also counselled that clients with mental health problems might dwell on retelling their story – their case history – rather than reflecting upon it or using their creative and imaginative ability to shape a life-story that was not a catalogue of their medical history. Some participants did demonstrate a desire to retell their medical history or narrative – including a recurring theme of the difficulty in gaining continuity with one trusted medical professional. I gently guided these participants back to fashioning a different and more creative narrative, with elements of scene creation, description and so on, by my first listening intently to and acknowledging their medical narrative for a few minutes and then suggesting we try to move beyond that. This simple strategy was largely successful; several participants commented explicitly that they were tired of having to retell their medical history to each new health professional they encountered in the hospital system, for example. My principal uncertainty was whether I should conduct the workshops at the same level of complexity that I had in the past with groups of university students or community groups. While in both of those cohorts there will often be some participants with mental health issues, for the most part this possibility does not affect the level or kind of content of material discussed in workshops. However, within this pilot group all had been diagnosed with moderate to severe mental illness, mostly schizophrenia, but also bipolar disorder and acute depression and anxiety disorders. The fact that my credentials were only as a published writer and teacher of creative writing, not as a health professional, was also a strong concern to me. But the clients readily accepted me as someone who knew the difficulty of writing well and getting published. I stressed to them that my primary aim was to teach effective creative writing as an end in itself. That it might be beneficial in health terms was secondary. It was a health professional who introduced me and briefly outlined the research aims of the workshop – including some attempt to measure qualitatively any possible benefits. It was my impression that the participants did not have a diminished sense of my usefulness because I was not a health professional. Their focus was on having the opportunity to practice creative writing and/or participate in a creative group activity. As mentioned above, I had prepared a workshop ‘kit’ for the participants of 15 pages. It contained the usual guidelines for effective writing – extracts from professional writers’ published work (including an extract from my own published work – a matter of equity, since they were allowing me to read their work), and a number of writing exercises (using description, concrete and abstract words, narrative point of view, writing in scenes, show don’t tell). The kit contained extracts from memoirs by Hugh Lunn and Bill Bryson, as well as a descriptive passage from Charles Dickens. An extract from Inga Clendinnen’s 2006 account in Agamemnon’s Kiss: selected essays of her positive interaction with fellow cancer patients (a narrative with the underlying theme of recovery) was also valuable for the participants. I stressed to the group that this material was very similar to that used with beginning writers among university students. I described the importance of life-writing as follows: Life-writing is simply telling a story from your life and perhaps musing or commenting on it at the same time. When you write a short account of something chosen from your life, you are making a pattern, using your memory, using your powers of description – you are being creative. You are being a story-teller. And story-telling is one very important thing that makes us humans different from all other animals – and it is a way in which we find a lot of meaning in our lives.My central advice in the kit was: “Just try to be as honest as you can – and to remember as well as you can … being honest and direct is both the best and the easiest way to write memoir”. The only major difference between my approach with these clients and that with a university class was in the selection of possible topics offered. In keeping with the advice of the psychologists who were experts in the theory of ‘recovery’, the topics were predominantly positive, though one or two topics gave the opportunity to recount and/or explore a negative experience if the participant wanted to do so: A time when I was able to help another personA time when I realised what really mattered in lifeA time when I overcame a major difficultyA time when I felt part of a group or teamA time when I knew what I wanted to do with my lifeA time when someone recognised a talent or quality of mineA time I did something that I was proud of A time when I learned something important to meA memorable time when I lived in a certain house or suburbA story that begins: “Looking back, I now understand that …”The group expressed satisfaction with these topics, though they had the usual writing students’ difficulty in choosing the one that best suited them. In the first two workshops we worked our way through the kit; in the third workshop, two weeks later, each participant read their own work to the group and received feedback from their peers and me. The feedback was encouraged to be positive and constructive, and the group spontaneously adopted a positive reinforcement approach, applauding each piece of writing. Workshop DynamicsThe venue for the workshops was a suburban house in the Logan area of Brisbane used as a drop-in centre for those with mental illness, and the majority of the participants would be familiar with it. It had a large, breezy deck on which a round-table configuration of seating was arranged. This veranda-type setting was sheltered enough to enable all to be heard easily and formal enough to emphasise a learning event was taking place; but it was also open enough to encourage a relaxed atmosphere. The week before the first workshop I visited the house to have lunch with a number of the participants. This gave me a sense of some of the participants’ personalities and degree of engagement, the way they related to each other, and in turn enabled them to begin to have some familiarity with me and ask questions. As a novice at working with this kind of client, I found this experience extremely valuable, especially as it suggested that a relatively high degree of communication and cognition would be possible, and it reduced the anxiety I had about pitching the workshops at an appropriate level. In the course of the first workshop, the most initially sceptical workshop participant ended up being the most engaged contributor. A highly intelligent woman, she felt it would be too upsetting to write about negative events, but ultimately wrote a very effective piece about the empowerment she gained from caring for a stray cat and locating the owner. Her narrative also expressed her realisation that the pet was partly a replacement for spending time with her son, who lived interstate. Another strong participant previously had written a book-length narrative of her years of misdiagnoses and trauma in the hospital system before coming under the care of her present health professionals. The participant who had the least literacy skills was accepted by the group as an equal and after a while contributed enthusiastically. Though he refused to sign the consent form at the outset, he asked to do so at the close of the first afternoon. The workshop was comprised of clients from two health provider organisations; at first the two groups tended to speak with those they already knew (as in any such situation in the broader community), but by the third workshop a sense of larger group identity was being manifested in their comments, as they spoke of what ‘the group’ would like in the future – such as their work being published in some form. It was clear that, as in a university setting, part of the beneficial effect of the workshops came from group and face to face interaction. It would be more difficult to have this dimension of benefit achieved via a web-based version of the workshops, though a chat room scenario would presumably go some way towards establishing a group feeling. Web-based delivery would certainly suit participants who lacked mobility or who lived in the regions. Clearly the Internet is a vital social networking tool, and an Internet-based version of the workshops could well be attempted in the future. My own previous experience of community digital storytelling workshops (Neilsen, Digital Storytelling as Life-writing) suggests that a high degree of technical proficiency can not be expected across such a cohort; but with adequate technical support, a program (the usual short, self-written script, recorded voice-over and still images scanned from the participants’ photo albums, etc) could make digital storytelling a further dimension of therapeutic life-writing for clients with mental illness. One of the most useful teaching techniques in a class room setting is the judicious use of humour – to create a sense of sharing a perspective, and simply to make material more entertaining. I tested the waters at the outset by referring to the mental health worker sitting in the background, and declaring (with some comic exaggeration) my concern that if I didn’t run the workshop well he would report adversely on me. There was general laughter and this expression of my vulnerability seemed to defuse anxiety on the part of some participants. As the workshop progressed I found I could use both humorous extracts of life-writing and ad hoc comic comments (never at the expense of a participant) as freely as in a university class. Participants made some droll comments in the overall context of encouraging one another in their contributions, both oral and written. Only one participant exhibited some temporary distress during one of the workshops. I was allowing another participant the freedom to digress from the main topic and the participant beside me displayed agitation and sharply demanded we get back to the point. I apologised and acknowledged I had not stayed as focused as I should and returned to the topic. I suspect I had a fortunate first experience of such arts therapy workshops – and that this was largely due to the voluntary nature of the study and that most of the participants brought a prior positive experience of the workshop scenario, and prior interest in creative writing, to the workshops. Outcomes A significantly positive outcome was that only one of the nine participants missed a session (through ill-health) and none left during workshops. The workshops tended to proceed longer than the three hours allotted on each occasion. Post-workshop interviews were conducted by a psychologist with the participants. Detailed data is not available yet – but there was a clear indication by almost all participants that they felt the workshops were beneficial and that they would like to participate in further workshops. All but one agreed to have their life-writing included in a newsletter produced by one of the sponsors of the workshops. The positive reception of the workshops by the participants has encouraged planning to be undertaken for a wide-ranging longitudinal study by means of a significant number of workshops in both life-writing and visual arts in more than one city, conducted by a team of health professionals and creative practitioners – this time with sophisticated measurement instruments to gauge the effectiveness of art therapy in aiding ‘recovery’. Small as the workshop group was, the pilot study seems to validate previous research in the UK and US as we have summarised above. The indications are that significant elements of recovery (in particular, feelings of enhanced agency and creativity), can be achieved by life-writing workshops that are guided by creative practitioners; and that it is the process of narrative construction within life-writing that engages with or enhances a sense of self and identity. NoteWe are indebted, in making the summary of the concept of ‘recovery’ in health science terms, to work in progress by the following research team: Robert King, Tom O'Brien and Claire Edwards (School of Medicine, University of Queensland), Margot Schofield and Patricia Fenner (School of Public Health, Latrobe University). We are also grateful for the generous assistance of both this group and Seiji Humphries from the Richmond Queensland Fellowship, in providing preparation for the workshops. ReferencesAlschuler, Mari. “Lifestories – Biography and Autobiography as Healing Tools for Adults with Mental Illness.” Journal of Poetry Therapy 11.2 (1997): 113–17.Davidson, Larry and John Strauss. “Sense of Self in Recovery from Severe Mental Illness.” British Journal of Medical Psychology 65 (1992): 31–45.Eakin, Paul. Fictions in Autobiography: Studies of the Art of Self-Invention. Princeton: Princeton UP, 1985.———. How Our Lives Become Stories: Making Selves. Ithaca: Cornell UP, 1999.Esterling, B.A., L. L’Abate., E.J. Murray, and J.W. Pennebaker. “Empirical Foundations for Writing in Prevention and Psychotherapy: Mental and Physical Health Outcomes.” Clinical Psychology Review 19.1 (1999): 79–96.Herman, Judith. Trauma and Recovery: The Aftermath of Violence - from Domestic Abuse to Political Terror. New York: Basic Books, 1992.King, Robert, Chris Lloyd, and Tom Meehan. Handbook of Psychosocial Rehabilitation. Oxford: Blackwell Publishing, 2007.Liberman, Robert, and Alex Kopelowicz. “Recovery from Schizophrenia: A Criterion-Based Definition.” In Ralph, R., and P. Corrigan (eds). Recovery in Mental Illness: Broadening Our Understanding of Wellness. Washington, DC: APA, 2005.Linder, Vicki. “The Tale of two Bethanies: Trauma in the Creative Writing Classroom.” New Writing: The International Journal for the Practice and Theory of Creative Writing 1.1 (2004): 6–14Murphy, Ffion, and Philip Neilsen. “Recuperating Writers – and Writing: The Potential of Writing Therapy.” TEXT 12.1 (Apr. 2008). ‹http://www.textjournal.com.au/april08/murphy_neilsen.htm›.Neilsen, Philip. “Digital Storytelling as Life-Writing: Self-Construction, Therapeutic Effect, Textual Analysis Leading to an Enabling ‘Aesthetic’ for the Community Voice.” ‹http://www.speculation2005.qut.edu.au/papers/Neilsen.pdf›.Pennebaker, James W., and Janel D. Seagal. “Forming a Story: The Health Benefits of Narrative.” Journal of Clinical Psychology, 55.10 (1999): 1243–54.Pennebaker, James W. “Telling Stories: The Health Benefits of Narrative.” Literature and Medicine 19.1 (2000): 3–18.Spandler, H., J. Secker, L. Kent, S. Hacking, and J. Shenton. “Catching Life: The Contribution of Arts Initiatives to ‘Recovery’ Approaches in Mental Health.” Journal of Psychiatric and Mental Health Nursing 14.8 (2007): 791–799.Wright, Jeannie, and Man Cheung Chung. “Mastery or Mystery? Therapeutic Writing: A Review of the Literature.” British Journal of Guidance and Counselling, 29.3 (2001): 277–91.

"Doctor, will I live longer if I give up alcohol and sex?" "No, but it will seem like it." The paradigm of the self as it is conceptualised in Western society includes an implicit assumption that one of the primary activities of the self is to engage in protective behaviours. This is a basic assumption in mass media promotion of healthy behaviours: 'Quit smoking' to protect yourself from lung cancer; 'Work safe' to protect yourself from injury, etc. Mass media social marketing campaigns inform the general population of the dangers to the self's existence of smoking, drink-driving, unsafe sex, over-eating, under-exercising and so on. These campaigns are based on models such as the Health Belief Model (Janz and Becker), the Fear Drive paradigm (Janis; McGuire), the Parallel Response Model (Leventhal), Thayer's Arousal Model, Roger's Protection Motivation Theory (Rogers & Mewborn; Maddux & Rogers), Ordered Protection Motivation Theory (Tanner, Hunt and Eppright) and the Extended Parallel Process Model (Witte). Fundamental to all these models is the assumption that people are motivated to protect themselves from harm. Information is provided that warns of the severity and likelihood of consequences of unhealthy behaviours. In some cases this information does motivate people to give up harmful behaviours and adopt safer options. However, worldwide, we see an increasing prevalence of diseases such as heart disease, diabetes and cancer that are related to preventable causes such as obesity, smoking and a sedentary lifestyle. To meet this challenge, the media strategy has generally focused on how to get health information across more effectively, that is, by making it more persuasive, more vivid, more salient, more imminent, more probable, and so on. Media exhortations to: 'say no to drugs', 'Quit because you can!', 'Respect yourself' etc. do not always achieve the desired change and may increase frustration, hopelessness and even depression (Henley & Donovan). It may be helpful to consider that this protection motivation paradigm does not take into account the prevalence of paradoxical behaviours, that is, behaviours that are harmful to the self (Apter). When talking about health, I think it is useful to divide paradoxical behaviours into two categories: thrill-seeking behaviours such as sky-diving and bungie-jumping where the individual enjoys the experience of being at risk without (usually) craving it; craved or 'addictive' behaviours (using the term loosely), such as smoking, binge-drinking, over-eating, drug-taking, where the individual craves a certain sensation and the gratification of the craving supersedes protective impulses. In both cases, the individual knows the behaviour is potentially harmful but chooses to engage in it. In the first case, there is a conscious choice that the enjoyment of the thrill experience outweighs the risk. The person feels in control of the decision (even if the decision is to abandon oneself to the feeling of being temporarily out of control). In the second case, there is a need to gratify the craving, regardless of the risk. The person is fully aware that it is not in their long term self-interest but feels out of control of the decision (Lowenstein). This second category of paradoxical behaviours consists of many unhealthy behaviours targeted by health practitioners. This paper discusses 1) the concept of the self in Western society; 2) the concept of paradoxical behaviour, distinguishing it from deviant behaviour; and 3) the suggestion that people may engage in addictive paradoxical behaviours to satisfy the 'empty self' (Cushman). Finally, the paper suggests that this attention to the empty self may be in a perverse way protective (though not healthy), and calls for a health promotion approach that directly addresses the needs of the 'empty self'. Concept of Self The concept of the self varies across cultures and time. Cushman (599) defined the concept of the self as 'the concept of the individual as articulated by the indigenous psychology of a particular cultural group.... the self embodies what the culture believes is humankind's place in the cosmos: its limits, talents, expectations, and prohibitions'. The Eastern concept of self extends 'beyond one's physical and psychosocial identity to include all other people in the world' (Westman & Canter 419) while the concept of self as it has developed in Western society 'has specific psychological boundaries, an internal locus of control, and a wish to manipulate the external world for its own personal ends' (Cushman 600). This Western concept of the self has been traced to Augustine's Confessions, identified by Weintraub (cited in Freeman 26) as the first reflective, autobiographical review of a life history in which selfhood is examined and understood. The concept of self encapsulates the most profound sense of cosmic place, worth and meaning. One of the aspects of the Western concept of self is a sense of mastery, of being able to act upon the world. Paradoxical vs Deviant Behaviour Apter makes a distinction between deviant behaviour, which is defined by social norms, and paradoxical behaviour, which is defined as any behaviour potentially harmful either to the individual or to society. Parachuting would be an example of behaviour potentially harmful to the individual, while celibacy, by threatening the survival of the social group, would be behaviour potentially harmful to society. Neither of these behaviours would be regarded as 'deviant'. Apter (10) calls this sort of behaviour paradoxical 'because it has the opposite effect to that which, from a biological and evolutionary point of view, one would expect behaviour to have'. While there will be considerable overlap in practice between deviant and paradoxical behaviour - child abuse, vandalism, drug and alcohol abuse, suicide, etc. would all be both deviant and paradoxical - there is a distinction in perspective between these two terms. Deviant behaviour, by definition, is always regarded by a society as anti-social (and therefore is often harmful); paradoxical behaviour is, by definition, always regarded by the individual's self-concept as harmful or potentially harmful (and therefore is also often anti-social). As our self-concept is socially learned, it is difficult to arrive at a true separation of these definitions but the following example may clarify the distinction: smoking was a widespread, socially acceptable activity in the 1950s, even glamorised by Hollywood. When the scientific evidence showed that it was harmful to the individual's health, that is, paradoxical behaviour, many people were sufficiently motivated to quit. Since the dangers of passive smoking have been highlighted and smoking is becoming regarded as socially unacceptable, that is, deviant behaviour, many more people are trying to stop, and succeeding. For many people, motivation for change is successful when an activity is recognised as both deviant and paradoxical. Social marketing campaigns have targeted these two areas for years, informing of health risks and dispelling the glamorous image. Yet, people still smoke, even when they know the health dangers and daily experience the open disapproval of others. At the extreme is the person who lies in a hospital bed with both legs amputated, being told and believing that continued smoking will result in the loss of remaining limbs, but who is still not motivated sufficiently to quit; this person is clearly exhibiting extreme paradoxical behaviour. It is useful to call this behaviour paradoxical rather than deviant because it is defined primarily by the extreme injury to the individual rather than the degree to which it departs from social norms. Why an individual would persist in such irrational behaviour is a seemingly unanswerable question. As Menninger has said, 'the extraordinary propensity of the human being to join hands with external forces in an attack upon his own existence is one of the most remarkable of biological phenomena' (cited in Apter 10). In trying to understand it, we look at three alternatives: 1) what people say their reasons may be; 2) how people defend against knowledge of risk; and 3) the role of visceral influences. Van Deurzen-Smith (165-6), an existential counsellor, gives some insight into the complexity of one of her patient's reasons for smoking: The dangers of heart disease or lung cancer had, far from making her want to give up smoking, been a real secret attraction which had been hard to give up. She had experienced smoking as playing with fire and that was highly enjoyable.... smoking in this sense had represented her experience of her body as concretely her own. Inhaling smoke was like breathing fire and feeling extra-alive; exhaling smoke was like seeing her own body's power being projected out of her mouth. Carrying cigarettes and fire on her every minute of the day used to give her a sense of oneness with the substances of the natural world; it was like possessing the secret power of some magical ritual. When smoking she was in command of the physical world, she was master of her own destiny. In other words, smoking had become an integral part of this person's self-concept. An alternative viewpoint is that smokers simply defend against knowledge of the health risks. In an examination of 'psychic defences against high fear appeals', Stuteville identified three techniques which people use to reduce fear-arousal: a) they deny the validity of the information; b) they unconsciously assert 'I am the exception to the rule - it won't happen to me'; and c) they defuse the danger by making it laughable or ridiculous. He suggested that campaigns can be more effective if they involve a threat to significant others, especially children, or are made to seem 'offensive to small group norms' (45), that is, seen as deviant rather than paradoxical. Lowenstein attempted to understand the discrepancies between what people do and what it is in their self-interest to do by postulating the operation of 'visceral factors', drive states relating to hunger, fear, pain, sex and emotions. He suggested that the need to satisfy these drives can supersede virtually all other needs, and that people consistently fail to recognise the strength of the influence of visceral factors in themselves and in others, despite all previous experience and evidence to the contrary. One of the characteristics of visceral factors is the effect of time-shortening so that immediate gratification outweighs long-term goals. Attempts to exercise self-control are made when thinking long-term and usually at the expense of short-term gratification (Lowenstein 288). Although this concept of visceral influences explains some irrational behaviour, Lowenstein made little attempt to explain why some people seem to be more at the mercy of visceral factors than others. For this, it may be helpful to explore Cushman's concept of the 'empty self'. The Hungry 'Empty Self' Cushman (600) identified the configuration of the concept of self in the United States as having developed into an 'empty self ... a self that experiences a significant absence of community, tradition, and shared meaning. It experiences these social absences and their consequences 'interiorly' as a lack of personal conviction and worth, and it embodies the absences as a chronic, undifferentiated emotional hunger'. It is this notion of emotional hunger that may have particular relevance to a discussion of paradoxical behaviours generated by cravings. Cushman referred to a strong desire for consumer products to assuage this hunger, but it may be useful when thinking of health to consider the hunger more literally, as a need to ingest substances (drugs, alcohol, food etc) and experiences (shopping, sex, speed, etc) to fill up the emptiness. Emotional hunger may lead to a number of self-destructive but self-nourishing and addictive habits, identified by Firestone as psychological defences against anxiety. Cushman identified advertising as one of the two professions responsible for healing the empty self (the other was psychotherapy), while recognising that it is also one of the professions that perpetuates and profits from the psychopathology. Perhaps the responsibility falls to social marketing which is concerned with the marketing of ideas, attitudes and beliefs, including health and safety lifestyle issues. At present, it could be said that health promotion tends to make people feel bad (Henley & Donovan), with an emphasis on the dire consequences of unhealthy behaviours. Is it reasonable to suggest that social marketing could be used to try to heal the empty self? Interestingly, this is already happening to some extent. Mental health is a priority issue and a recent mental health campaign in Victoria, Australia, 'Together We Do Better', stresses the need for community and social connection. Western Australia is exploring whether to undertake a similar campaign. The campaign includes messages relating to friendship, parenting, talking about problems, bullying, sledging, and inter-generational communication (Campaign materials). The overall aim is to work towards a more inclusive, caring, connected and tolerant society. Conclusion This paper has discussed the apparent limitation of the current paradigm in health promotion that people are primarily motivated to protect themselves by considering the prevalence of paradoxical behaviours, that is behaviours that are harmful to the self, especially those that are generated by a need to satisfy cravings. One explanation for such paradoxical behaviours is that they are motivated by visceral factors relating to physical and emotional drives. However, this does not explain why some people are more susceptible than others. Cushman's concept of the hungry, empty self, alienated from community and disconnected from social traditions and meaning, may go further to explain why some people are more susceptible to cravings than others. Social marketing could play a helpful role in healing people's sense of isolation in mental health campaigns such as VicHealth's 'Together We Do Better'. Finally, it may be more intuitive to understand apparently paradoxical behaviour as an urgent attempt to heal the empty self. This would make it in a perverse way protective, though not healthy. This way, people are seen as doing the best they can to protect themselves against the most immediate threat to the self, a sense of hollowness and isolation. If so, the fact that this need is able to supersede other major health needs suggests that it is one of the most urgent imperatives of the self. References Apter, M.J. 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