CQ 2013-1 Open Forum

CQ

The CAPA Quarterly

Issue One 2013

Journal of the Counsellors and Psychotherapists Association of NSW, Inc.

Welcome

Editorial

Genuine beginnings begin within us, even when they are brought to our attention by external opportunities. ~William Throsby Bridges

A new year is upon us. The silly season is over, the champagne glasses have been returned to the cupboard, and if you are feeling anything like I am, you are ready to roll up your sleeves and eagerly step into whatever 2013 has in store for you. We witnessed many changes in 2012 for both CAPA and CQ, and 2013 heralds a new start and a new chapter, especially here at CQ. I am looking forward to sharing the wonderful themed issues we have planned for you this year.

I have big shoes to fill with the departure of CQ ’s Editor, Laura Daniel, but I feel very lucky to have had the opportunity, this past year, as Deputy Editor to learn as much as I can from Laura—who has so generously shared her time, knowledge and expertise. No one could have asked for a better mentor, and I wish her the very best in the exciting, new endeavours that await her. I am also pleased and honoured to continue to have the opportunity to work with the many contributors who so generously give of their time to CQ, the members of the Executive Committee who are always so encouraging and happy to assist, our regular columnist, whose wit and fresh perspective continues to engage us, and of course, the Office Coordinator and Administrative Assistant whose support is invaluable.

A full year has passed since the February issue was first designated an Open Forum, rather than a themed issue, which means we have the opportunity each year to feature a diverse range of therapy topics that might otherwise not appear for lack of a relevant fit within a themed issue. I am delighted, therefore, to start my introduction of this issue with an article

by Stephen Malloch, who shares his thoughts on the musical nature of his communication with clients and the basis for his further research in 2013.

Victoria Harrison provides an overview of Bowen Therapy and a case study exploring this family systems perspective within a psychotherapeutic context.

Elizabeth Conroy and Monica Thielking both have extensive experience working with homeless persons. They discuss the increasingly important issue of homelessness, the factors that can contribute to homelessness, its effects on mental health and the therapeutic considerations when working with a homeless person.

After a decade of practice and research into the treatment of trauma using vocal improvisation, psychotherapist Kirstin Robertson-Gillam shares her knowledge and insights about ways to help people express and release their trauma.

February 2013

Jane Kohlhoff and Bryanne Barnett, a psychologist and psychiatrist, respectively, with Karitane, investigate the importance of early intervention and care for maternal depression and anxiety in the perinatal period. Using a case study, they illustrate the effectiveness of such intervention.

In an overview of Positive Psychology, Suzy Green discusses the role the therapist can have in preventing mental illness and promoting wellbeing.

In this quarter’s Modality Profile, we feature neurofeedback.

Jewel Jones in her regular column, In the Therapy Room, speaks to us of time.

Finally, I understand that the development of the CAPA website has suffered some delays in going live, but all efforts are being made to ensure this happens as soon as possible.

CQ contributor guidelines and advertising rates and specs will eventually be found there; but in the meantime, that information can also be obtained from office@capa.asn.au, editor@capa.asn.au or advertising@capa.asn.au, depending on the nature of your enquiry.

As always, this journal is for you, our valued members, and I enthusiastically encourage your active participation in the professional dialogue and sharing that this journal provides.

Please have a look at the upcoming themes announced on Page 36 of this issue and have your say on the topics that interest you. Journal articles are, by the nature of page space, limited, and early contact with me improves the chances of your contribution being included. Dialogue is welcome and encouraged. If you’d like to contribute to future issues, please contact me at editor@capa.asn.au.

Roberta Parrott Editor

Roberta Parrott, BA, Dip. is a freelance editor based in Sydney. She is a keen student of art history and languages, particularly French and Spanish and travels every chance she gets. Trained also as a Cordon Bleu chef, she balances her passion for cooking with an active lifestyle.

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Contents CAPA NSW Executive and Staff President Gina O’Neill president@capa.asn.au Vice-President Jane Ewins vicepresident@capa.asn.au Secretary Vacant secretary@capa.asn.au Treasurer Juliana Triml treasurer@capa.asn.au Ethics Chair Tara Gulliver ethics@capa.asn.au Membership Chair Linda MacKay membership@capa.asn.au Regional and Rural Liaison Chair Sharon Ellam regional@capa.asn.au Professional Recognition Chair Ebinepre Cocodia recognition@capa.asn.au Liaison Chair Alison Hood liaison@capa.asn.au Executive Member Tim Harvey webdev@capa.asn.au Executive Member Linda Newcomb strategy@capa.asn.au PD Coordinator Juliana Triml pde@capa.asn.au Office Coordinator Paul Dudley office@capa.asn.au Administrative Assistant Freddy Ortega office@capa.asn.au CQ: The CAPA Quarterly Editor Roberta Parrott editor@capa.asn.au

Welcome

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Editorial ~ Roberta Parrott

CAPA News 3 4 6

From the President’s Desk ~ Gina O’Neill CAPA News Regional and Rural Report ~ Sharon Ellam

First Person 8

Communicative Musicality: Its Application in Talking Therapies ~ Stephen Malloch

Features 10 A Wider Lens: Bowen Theory and a Natural Systems View of Symptoms ~ Victoria Harrison 14 The Mental Health of Homeless Persons ~ Elizabeth Conroy and Monica Thielking 18 Breaking the Silence and Singing Out the Pain: Voice Work for Traumatised Clients ~ Kirstin Robertson-Gillam, Michael Atherton and Leon Petchkovsky 22 Maternal Depression and Anxiety in the Perinatal Period: Predictors, Impacts and Treatments ~ Jane Kohlhoff and Bryanne Barnett 26 Positive Mental Health: Contributions from the Science of Positive Psychology ~ Suzy Green Modality Profile 28 Neurofeedback In the Therapy Room 30 Tick-Tock, Watch The Clock ~ Jewel Jones Professional Development 32 Exploring Ethical Practice ~ Review by Juliana Triml 33 Professional Development Events Noticeboard 36 Calls for Contributions & Ad Rates Inside Back Cover Classifieds Back Cover Conference Calendar = Peer Reviewed

Advertising Coordinator Roberta Parrott advertising@capa.asn.au

Peer-reviewed articles in this journal have undergone rigorous peer review, based on initial editor screening and double-blind review refereeing by at least two anonymous scholars.

CQ: The CAPA Quarterly respectfully acknowledges the Cadigal people of the Eora Nation, the traditional owners and custodians of the land on which the CAPA NSW office is located; and the traditional owners of all the lands through which this journal may pass.

Cover art by Jim Frazier Design by Sarah Marsden Printed by Unik Printing ISSN 1835-937X

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© CAPA NSW 2011. Copyright is held with CAPA NSW and individual authors. Please direct permission requests to the editor. Opinions expressed in CQ: The CAPA Quarterly do not necessarily represent those of the Editor or of CAPA NSW. While all reasonable care has been taken in the preparation of this publication, no liability is assumed for any errors or omissions. Liability howsoever as a result of use or reliance upon advice, representation, statement or opinion expressed in The CAPA Quarterly is expressly disclaimed by CAPA NSW and all persons involved in the preparation of this publication. The appearance of an advertisement in CQ: The CAPA Quarterly does not imply endorsement of the service or approval of professional development hours from the service. Advertisers are advised that all advertising is their responsibility under the Trade Practices Act.

CQ: The CAPA Quarterly

CAPA News

From the President’s Desk Welcome to 2013!

I would like to start by first thanking and acknowledging Jeni Marin for all her hard work as President of CAPA until her resignation in late 2012. On behalf of the current Executive, we wish her all the best in her future academic ventures.

This promises to be a year of great excitement and growth for CAPA NSW after a very well-attended and productive EGM/Xmas party held in December 2012. The EGM provided members with a look at where we currently are and what our choices are going forward—of which, there are many to think about. The World Café resulted in a cohesive and strong vision for CAPA NSW’s future.

The theme of ‘one voice’ uniting our profession was strong.

The members of CAPA continued to support the Executive, and we walked away from the meeting with a feeling of satisfaction and a comprehensive list of people offering expertise and assistance to realise CAPA’s future plans—to stay relevant and hold value in our ever-changing and growing industry.

By the time this issue goes to print, the Executive will have attended the planning meeting to detail how the CAPA Executive will undertake and carry out the World Café vision taken from the EGM. This will take time and man-power, which I believe we now have, so expect more positive changes for CAPA. We will keep you all informed every step of the way.

This year we welcome Roberta Parrott as the new Editor of CQ, farewelling Laura Daniel. Laura greatly raised the standard of the journal in the quality of both content and visual presentation. We are fortunate to have had at the helm such a seasoned professional with such a wealth of experience. On behalf of the Executive Committee, I thank Laura for her passion and creativity throughout her tenure as CQ ’s Editor.

The website is very close to becoming a reality for all of our members this year. I would like to thank Barry Borham for his professional approach with the website and his eye for detail.

We have some exciting PD events coming up this year also, which you will read about in this issue. If you are able to devote a small amount of time to assist us in finding and liaising with speakers to attend the PD events, it would be much appreciated as we are always looking for new speakers. Juliana Triml puts a great deal of time into our PD events—the planning and delivery. Again, thank you Juliana.

Finally, I would like to thank all of you who attended the CAPA NSW EGM in December. It is very encouraging for the staff and the Executive Committee members alike to see how we can connect and revision our member association during this time of change. We now know that the membership wishes to build CAPA NSW to become more relevant, have a stronger presence in our industry and a reputation for nurturing members throughout all stages of their careers. I also take great pleasure in welcoming and introducing the new Executive Committee in this first issue for 2013 and I thank each of them for giving so generously of their time and of themselves.

I hope that you enjoy this eclectic edition of CQ: The CAPA Quarterly.

Warm wishes,

Gina O’Neill President president@capa.asn.au

Code of Conduct for Unregistered Health Practitioners As counsellors and psychotherapists, we are legally required to display two documents in our practice(s): • t he NSW Code of Conduct for Unregistered Health Practitioners • information on how clients can make formal complaints to the Health Care Complaints Commission.

Both are available online in the members area of the CAPA NSW website: www.capa.asn.au The Code of Conduct is also available in several community languages on the Health Care Complaints Commission website: www.hccc.nsw.gov.au These legal requirements are set out in ‘Public Health (General) Amendment Regulation 2008’ under the NSW Public Health Act (1991), and came into effect on 01/08/2008.

February 2013

Ethics Checkout the CAPA NSW website for information on: • Ethics and Counselling • Problem Solving Steps • Client Confidentiality and Privacy and Relevant NSW and Commonwealth Legislation • Duty of Care • Workplace Bullying and Violence • Mandatory Reporting • Keeping Track of Paperwork • Information for Counsellors who have been served with Subpoenas • Complaints Form for Submission of Complaints and Grievances by a CAPA Member Just login to the members area of www.capa.asn.au and click on the “Ethics” button on the left.

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CAPA News

New CAPA Executive for 2013 Following on from the CAPA EGM held in December 2012, we are pleased to welcome and to introduce the newly elected members of the CAPA Executive Committee for the 2013 administrative year.

President – Gina O’Neill president@capa.asn.au Gina is currently completing her Masters in Gestalt Psychotherapy this year. She is based in Sydney’s Northern Beaches. Working in a private psychiatric setting treating individuals with various addictions and mood disorders at South Pacific Private, she is known for her work with childhood trauma and its link with adult mental health issues.

As Gina’s cultural background is from a multicultural perspective, her interest and increasing area of speciality is cross-cultural therapy. Having foundations in working with families of individuals with addictions and mood disordered issues, she is able to work with a larger field perspective and enjoys communicating openly to other clinicians from a multi-disciplinary approach both in her private practice and hospital settings.

Vice-President – Jane Ewins vicepresident@capa.asn.au Jane is a counsellor, supervisor, and facilitator based in the Shoalhaven District (south coast NSW). Through her business Soulvable Consulting, she also consults to the business and community service sectors in the areas of organisational management, communications and marketing.

Earlier in her career, Jane worked as a counsellor and advocate for charities and non-government organisations including Anglicare, Sydney Adventist Hospital Cancer Support Centre, the Family Relationship Centre (Shoalhaven) and Catholic Care.

She has developed or run programs, workshops and ‘strategic visioning days’ for organisations including the Cancer Council (NSW), Quest for Life, Anglicare, Catholic Care, Good Beginnings, The Coalition for Australia’s Children, Create and Dads Inc., and NAPCAN. Treasurer – Juliana Triml treasurer@capa.asn.au Juliana started her working life as an accountant. In 1998, she completed a degree in Psychology and Sociology at Monash University, a Postgraduate Diploma in Counselling from ACAP in 2000, a Masters at the UWS and then a Masters Honours in 2007.

Her counselling style integrates elements of the Existential, Buddhist and ACT philosophies.

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Since establishing her private practice in 2000, Juliana has held part-time counselling positions with an NGO in Fairfield and a methadone clinic in the CBD. She has an interest in addiction and continues to work part-time at the methadone clinic. She is on the Carers NSW register, PACFA register, Workcover register and is a board member of Hepatitis NSW. Juliana also works part-time with a carer’s respite organization in Northern Sydney. Since 2010, Juliana has managed and coordinated CAPA’s Professional Development Events and has been involved in inviting and selecting CAPA 2012 Conference presenters.

Ethics Chair – Tara Gulliver ethics@capa.asn.au Tara has been a volunteer with Lifeline for twenty-four years. She started as a telephone counsellor and then continued her training at the Institute of Counselling with a Graduate Diploma of Counselling, furthering her studies at Unifam with a Diploma of Individual, Couple and Family Therapy. Still with Lifeline, Tara moved into personal, family and relationship counselling.

She has also completed extensive Personal Development inservices with Lifeline. Trained as a Suicide Awareness and Prevention Educator with Living Works for two years, Tara was coordinator of the suicide support scheme for the northern beaches in Sydney. For the last five years, in conjunction with the Department of Probation and Parole and local community services, Tara has facilitated men’s anger management groups. She has recently joined the CAPA Ethics Committee and is a clinical member of CAPA and a member of PACFA .

Membership Chair – Linda MacKay membership@capa.asn.au Linda MacKay has a well-established reputation in the counselling and family therapy fields in Australia. She is a faculty member of The Family Systems Institute in Sydney and is passionate about teaching health professionals about working with clients from a Bowen family systems theory perspective.

Linda is also a neurofeedback trainer working with private individuals and business executives who wish to optimise their performance as leaders. She is currently a lecturer in the post-graduate psychology program at the Australian Catholic CQ: The CAPA Quarterly

University and is the clinical supervisor of CAMHS, and other Health and NGO teams across NSW and the StandBy Post-Suicide Response Service for Northern Tasmania. (Yes, even from NSW!) Regional & Rural Liaison Chair – Sharon Ellam regional@capa.asn.au Sharon is based on the western shores of Lake Macquarie. Working in private practice with individuals, couples and families, she is known in the Newcastle/Central Coast area as having a particular interest in childhood anxiety. With an eclectic approach, but a strong emphasis on building resilient family systems, she works with children and their parents as a single entity. With very young children, she aims to effect change through re-focussing parental behaviours, and teaching them a child-specific ‘language’ to begin the process of teaching their child to self-calm and seek help.

She compliments her practice by teaching piano. As well as paying the bills, combining counselling with piano teaching is a strategic decision in managing her self-care, which is another priority in her life.

Professional Recognition Chair – Ebinepre Cocodia recognition@capa.asn.au Ebi is a general counsellor and head of the counselling discipline at University of Notre Dame Australia, Sydney campus.

She completed her PhD in Educational Psychology at the University of New South Wales in 2004, holds Masters degrees in Counselling and Education, and has taught a range of counselling and educational psychology courses. Ebi does face-to-face counselling at Lifeline and has a private practice in the CBD. Her main research interests are in the fields of counsellor education and training, student motivation, migrant counselling and the psychology of human intelligence. These areas are directly related to her teaching areas, which focus on reflective practice in counselling and counsellor education.

Liaison Chair – Alison Hood liaison@capa.asn.au Alison grew up in Thatcher’s Britain, is passionate about social justice and has worked in marketing communications, fundraising and brand development with not-for-profit organisations in the UK and Australia for about twenty-three years.

February 2013

In 2002, she emigrated to Australia where she has trained and, subsequently, worked as a counsellor and groupworker with a Melbourne palliative care service. Alison now works with an inner-city, community-based service for asylum seekers and refugees, where she marvels on a daily basis at the resilience of the human spirit.

Alison joined CAPA NSW as an intern in 2011 and became a provisional clinical member in 2012. She holds a Master in Human Rights and is currently in the final stages of a Master of Counselling.

Executive Member – Tim Harvey webdev@capa.asn.au With over twenty years’ experience at Lifeline as a telephone and face-to-face counsellor, running groups, and as a trainer of Lifeline counsellors, Tim has designed and facilitated many men’s and women’s anger management groups and has trained counsellors at Cottage Counselling and employees at a number of commercial and educational institutions. He has been in private practice as a counsellor/psychotherapist for ten years.

Tim specialises in relationships, men’s issues, conflict resolution and business coaching. He is the founder of Tim Harvey and Associates, which has an office in Nowra on the NSW South Coast and is exploring the potential of the internet for counselling, supervision, training and group communications. He will assist the Liaison Committee with the development of CAPA’s website.

Executive Member – Linda Newcomb strategy@capa.asn.au As a Centre Supervisor at Lifeline Northern Beaches, Linda supervises, debriefs and coaches the volunteer crisis supporters who respond to calls received by the Lifeline Suicide Crisis Line 131114 and conducts crisis interventions for suicidal or at risk callers. Linda also co-ordinates two telephone support programs: a suicidal crisis support call-back program and a care-ring program. She volunteers as a face-to-face counsellor at Lifeline Northern Beaches and has contributed to the design, conduct and reporting of a six-week gambling support program for problem gamblers. She has worked casually on the National Domestic Violence and Sexual Assault Helpline. Linda is currently an intern member of CAPA working towards clinical member status and will assist the Committee with CAPA’s strategic review and planning.

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Regional and Rural Report

Our Future: W hat There has to be some kind of purpose to writing this report on Remembrance Day 2012—as a time to reflect what is past, what is present and what is yet to come. By the time this report is read, I hope that there will be new purpose and energy within CAPA and this Executive Committee.

As a member of the Committee, I’m counting down to the Extraordinary General Meeting to be held on 1 December 2012. Change must come.

What is in the past? In 2012, this Committee has seen a gradual weakening of strength in numbers and an increase in workload for those left behind. Increasing strain on the Executive Committee meant that, at various times, as Regional & Rural Liaison Chair, I also took on the additional roles of Website Liaison and Secretary. At the same time, some important things got done, for example, placing an online PDE on the agenda. We saw a gradual increase in recognition of CAPA at the NSW Mental Health Network meetings in Sydney and at the NSW Farmers’ Association, as we participated in public discussions about the mental health needs of regional communities affected by land-use conflicts, such as Coal Seam Gas exploration.

Unfortunately, both regional PDEs planned were cancelled.

The present is now. Change within CAPA is imminent.

Professionally, we are at the stage where we need to take personal responsibility for our work. That means standing up to be counted, making sure that we all individually take positive steps to fulfil our duties professionally (not simply relying on someone else to do it for us), and finally that we have the courage to look outside the square from within our own sphere. Mihaly Csikszentmihalyi asks us to think: “Wait a minute, this is not all we can be, this is not all we can do. There are better ways of doing it.” He reminds us that there is “a possibility of getting beyond what you learned before” (Debold 2002).

In this life, we essentially have two choices: to act or to float. If we choose to float along, keeping the status quo, we experience a state of entropy—individually and collectively.

If we choose to act, it means that we have to change, to expend energy and thought, or to perhaps even go outside our comfort zones. If www.brainyquote.com can be believed, Eleanor Roosevelt said, “It takes as much energy to wish as it does to plan.” I wish … so I choose … to act.

To act for what is yet to come means that I choose to join.

The first question I ask myself is always, “How do I join

Journal ads and PD hours Please note that advertisements in the journal do not necessarily comply with CAPA’s professional development (PD) requirements.

As with all workshops/courses/conferences, please check their eligibility using CAPA’s ‘Professional Development Policy 2009/2010’ in the members area of the website www.capa.asn.au If you have any queries, please contact CAPA’s Membership Chair on membership@capa.asn.au 6

CQ: The CAPA Quarterly

W ill W e Make of It? when I live two hours away from Sydney—a place that I loathe the thought of driving to?” In speaking with other regional members, I know I’m not alone in asking this question. My reality and the reality for members of the Executive and other committees is that we think outside the square. It’s not realistic anymore to have committees where people meet at the same table with a cup of tea every month. We live too far away. We have schedules that collide, rather than fit.

To source that special wisdom from all of our members, we are choosing to find other ways to connect to get the job done. We use our landlines to speak or to have a group teleconference. (Teleconferences are charged to CAPA’s account.) We use our mobile phones to speak to or to text each other. Our email accounts are used for information sharing, discussions, voting and connecting for most of our work. Our CAPA emails are automatically forwarded to our own email addresses. We use the internet to share documents in a central place and to Skype. For those who don’t know, Skype is a computer application that facilitates a video or audio call with someone over the internet. The program is free to download and is trusted by many counsellors who also use it for counselling or supervision with clients. With a

reliable internet connection (medium speed or greater), this is a valuable way of connecting in real time.

So what is yet to come is whatever we choose to create. If you like what we do, please join us so it can continue. If you don’t like what we do, please join us so it can improve. It’s now 2013, what will we do with it?

There are those who look at things the way they are, and ask why ... I dream of things that never were, and ask why not? ~Robert Kennedy

Take care,

Sharon

Sharon Ellam, Chair Regional and Rural Committee

References Debold, E 2002, ‘Flow with Soul: An Interview with Dr Mihaly Csikszentmihalyi’, EnlightenNext magazine, 21 (Spring-Summer) viewed on 11/11/2012 at http://www.enlightennext.org/magazine/j21/csiksz.asp?page=1

You don’t want to write an academic paper?

We welcome more informal anecdotes from your practice.

Topics could include: • A client who changed my practice (or my life) • The most valuable lesson I learned in the therapy room • Ideas that inform my practice • My most important therapeutic mistake • Some things I wish I had known before becoming a therapist

Membership Total as at 1 December 2012 Clinical Member 400 Intern Member 111 Provisional Member 64 Student Member 46 Affiliate Member 29 Special Leave 1 Life Honorary Member 3 Total Financial Members 660

Send your submissions to editor@capa.asn.au

February 2013

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First Person

Communicative Musicality:

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I will focus on an event in this session that illustrates what I call the ‘gestural narratives’ that were occurring in tandem with the topics under discussion. Around ten minutes after the start of our meeting, Mark began to talk of a war going on between two parts of himself—“old me” and “new me”. “Old me” was, he said, primarily about a “lack of self-respect … everything that is going wrong is my fault.” “New me” is “more rational about life”: if he behaves in a way he feels is not the way he would like to behave he thinks, “that’s okay”, and then charts a course that addresses any unwanted outcomes.

What I am interested in here are the ‘vocal melodies’ he employed as he talked about the two parts of himself. Figure 1 shows a typical example of the changing pitch of his voice as he was talking of ‘old me’, and Figure 2 is a typical example of him talking about ‘new me’.

Pitch (Hz)

250

0 224.5

Time (s)

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Figure 1: Old Me 250

Pitch (Hz)

We are all musical. We have the ability to move in time to a beat, enjoy listening to a CD, remember a favourite tune. We are like this from birth. In a study carried out in the early 1990s, it was found that babies a mere two to four days old whose pregnant mothers had regularly watched the TV show Neighbours recognised that show’s theme song by showing noticeable relaxation, increased alertness, and decreased heart rate (Hepper 1991). When babies were presented with a phrase of Mozart’s music that was either the original, or that had been tampered with by adding a pause in the middle of the phrase, babies preferred the original unaltered phrase (Jusczyk & Krumhansl 1993). Again and again, babies have been shown to be highly sensitive to musical qualities. They are able to detect pitch changes of a semitone (Trehub et al.

1986), prefer consonant to dissonant harmonies (Trainor & Heinmiller 1998), and group rhythms in the same way as adults (Thorpe & Trehub 1989).

This and similar evidence led me to write, along with my friend and colleague Colwyn Trevarthen from Edinburgh University, that music and dance “attune to the essential efforts that the mind makes to regulate the body … in its purposeful engagements with the objects of the world, and with other people” (Trevarthen & Malloch 2000:11). Music and dance come out of the way the mind and body move through time in an innately organised fashion as we collaborate with the thoughts and movements of others. When we are with others, there is a co-created ‘song and dance’, seen in the moment-to-moment movements of body and voice. I called this innate way we interact with others through time Communicative Musicality (Malloch 1999/2000, Malloch & Trevarthen 2008). I called it communicative because it underlies all our communicative endeavours; I called it musical because it consists of the basic building blocks of music and dance.

Recently, I have been considering the implications of this for therapy. I work with clients in a typical talking fashion; but if we are all innately musical, then our musicality must be playing out in my interactions with my clients, regardless of the modality being used. In this brief paper, I present ways I have been thinking about and making use of musicality in conversations with my clients.

‘Mark’* is in his early 40s. At the time of this case study, he had been coming to see me for a little over three years for issues of ongoing anxiety around relationships at work and home. In our early sessions he had talked of great difficulty in offering his viewpoint—usually trying to guess what the other person wanted to hear and offering that. By the time of the session presented here, Mark was reporting far less frequent and far less intense anxiety experiences, and when they happened he was managing very successfully. Overall, he was getting on with his life and making decisions about his future. Mark concluded therapy with me a few months later.

0 224.5

Time (s)

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Figure 2: New Me It is clear from these two graphs that the gestural narratives of the voice—the vocal melodies that accompany the words— are very different for the two different sorts of ‘me’. ‘Old me’ is relatively flat and monotonic. ‘New me’ is much more contoured—moving through larger pitch changes. The different melodic qualities of these two parts represent differences in the effort Mark is making to produce the sounds with his larynx and diaphragm. The differences in effort were also played out through Mark’s body movements. When talking of ‘old me’ Mark was relatively static, sitting with arms crossed. When talking of ‘new me’ he uncrossed his arms and started to move with his speech.

These different vocal and body movement qualities create the different gestural narratives of these two ways of being. The two gestural narratives will also be representative of the differences CQ: The CAPA Quarterly

Its Application in Talking Therapies in how Mark moves in the world when acting out these two different parts of himself—which will influence the responses, in both words and movements, of those around him.

How Have I Used this Information as I Have Worked with Mark and Others?

First, I realised that I was being directly affected by the effortful movements of my client. Studies on mirror neurons suggest that one of the ways I understand the emotional content of movements of others is that I know how I would feel if I were to move in that way (Gallese et al. 2004). So giving focussed attention to my client’s movements of voice, hands, and body can heighten insight into the client’s inner world, because my mirror neurone system is obtaining high quality information to work with. This took practice. I at first found it quite difficult to pay attention to both verbal meaning and gestural narratives without losing track of one of them. I would sometimes realise I had a great feel for the gestural narrative, but had no idea what my client had just said!

Second, I began thinking about the interaction between myself and my client in terms of musical structures. In the ways pieces are written by composers such as Mozart, Beethoven and so on, a tune (or ‘theme’ as it is called) is introduced at the start, a different theme comes after it to provide contrast, then the two themes are changed and developed and worked out.

They might be brought together, small parts of them might be repeated and changed, different instruments might throw the tunes back and forth. A feeling of musical drama is created.

After this, the drama resolves and the original theme returns to close the piece, but we hear the return of the theme differently from how we heard it when it first appeared because of all that has happened during the course of the piece.

I have been experimenting with what it would mean to experience, in real time, a session with a client in terms similar to a musical structure like the one I have just described. A client comes in to my practice room, he or she sits and begins to speak and to move while speaking. What theme is emerging as my client and I interact. Is the gestural narrative angular and urgent or curved and languid? What is the verbal meaning of what is being said? I am curious about the interaction between the unfolding gestural narrative and the verbal narrative. I am curious about the ways I am participating in and being affected by these two streams of narratives, and where I sense they are leading.

As we sit and interact during the unfolding of that initial theme, something else will then begin to emerge. The theme might develop and deepen, or perhaps a new aspect that was implicit in the original presentation of the theme might suddenly become apparent. Or a new contrasting theme might appear—like the ‘new me’ that appeared after the ‘old me’ for Mark. Or perhaps I feel there is a theme that is wanting to be heard, but hasn’t arrived yet.

Is there something I need to do that will elicit this implicit theme?

And when drama, obvious or understated, occurs in the session, February 2013

Stephen Malloch

is this the sound of two or more themes working themselves out?

How do I participate in a way that honours the importance of this moment in the unfoldment of the therapy structure of this session and the series of sessions, but that doesn’t either influence a resolution too soon, so that the musicality becomes stunted, or perhaps overly encourage it, so that the drama starts to take over and thwart an emerging structural whole? And when themes return, even though they might sound almost exactly the same as when they first appeared, how does what has come before change the way this returned theme is experienced?

I try to experience the interaction between myself and my client both synchronically (feeling the experience of myself and my client in a single point in time) and diachronically (holding an overview of the process of the unfolding structure through time, where themes enter and leave, change and return). I ask myself, “How is the structure coming along? In what ways is the structure needing my input?”

As the therapist, it’s about my sense of balance in each unfolding moment of the therapy session, and bringing a musical sensitivity to how the moment is part of a larger, living structure.

This is my current thinking. From next year, I will be researching the ways therapists and clients communicate with each other, along with colleagues from Linguistics and Psychotherapy at the Sydney University Medical School. In a year’s time I will have more to say. *Names and any potentially identifying information have been changed and recording was undertaken with my client’s permission.

References Gallese, V, Keysers, C and Rizzolatti, G 2004, ‘A Unifying View of the Basis of Social Cognition’, TRENDS in Cognitive Sciences, 8 (9): 396-403 Hepper, PG 1991, ‘An Examination of Fetal Learning Before and After Birth’, Irish Journal of Psychology, 12: 95-107 Jusczyk, PW and Krumhansl, CL 1993, ‘Pitch and Rhythmic Patterns Affecting Infants’ Sensitivity to Musical Phrase Structure’, Journal of Experimental Psychology: Human Perception and Performance, 19: 627-640 Malloch, S 1999/2000, ‘Mothers and Infants and Communicative Musicality’, Special Issue of Musicae Scientiae: Rhythm, Musical Narrative and Origins of Human Communication, 29-57 Malloch, S and Trevarthen, C (Eds) 2008, Communicative Musicality: Exploring the Basis of Human Companionship, Oxford: Oxford University Press Thorpe, LA and Trehub, SE 1989, ‘Duration Illusion and Auditory Grouping in Infancy’, Developmental Psychology, 25: 122-127 Trainor, LJ and Heinmiller, BM 1998, ‘The Development of Evaluative Responses to Music: Infants Prefer to Listen to Consonance Over Dissonance’, Infant Behavior and Development, 21: 77-88 Trehub, SE, Cohen, AJ, Thorpe, LA and Morrongiello, BA 1986, ‘Development of the Perception of Musical Relations: Semitone and Diatonic Structure’, Journal of Experimental Psychology: Human Perception and Performance, 12: 295-301 Trevarthen, C and Malloch, S 2000, ‘The Dance of Wellbeing: Defining the Musical Therapeutic Effect’, The Nordic Journal of Music Therapy, 9 (2): 3-17

Dr Stephen Malloch works as a counsellor and executive coach (see www.heartmind.com.au), based in Mosman, Sydney. Originally trained as a musician, he has worked in research psychology at the University of Edinburgh and University of Western Sydney. His theory of Communicative Musicality is used by a wide variety of authors and researchers in areas as diverse as developmental psychology and music therapy. Stephen can be contacted on stephen.malloch@heartmind.com.au and PO Box 272, Spit Junction, NSW 2088.

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A Wider Lens: Bowen Theory and a relationship system and by the intensity of emotional fusion or level of differentiation of self.

‘Emotional fusion’ is a term that Bowen developed to capture the extent to which family members are ‘stuck together’ or connected in such interdependent fashion that reactivity in one registers in all. Degrees of emotional fusion are present for everyone and in every family. The intensity varies with the levels of differentiation of self.

The ‘scale of differentiation of self ’ describes a continuum from lower to higher degrees of fusion between family members that corresponds to the interplay between emotional and intellectual functioning within individuals. Bowen wrote: There are varying degrees of fusion between emotional and Bowen Theory and a Natural Systems intellectual systems in the human. The greater the fusion View of Symptoms A systems view of symptoms offers an alternative to cause between emotion and intellect, the more the individual is and effect thinking and to the focus on an individual fused into people around him … and the less he is able to unit—whether cell or person or relationship—as the problem consciously control his own life (Bowen 1978:305).

(GAP 1970). Murray Bowen (1913–1990) developed a That said, natural systems theory of human functioning, based on It is possible for man to discriminate between the emotions the study of the family as a system and upon research from and the intellect and to slowly gain more conscious control of evolution and the natural sciences. He organised careful emotional functioning (Bowen 1978:105). observation of families into eight concepts and described two With greater differentiation of self, individuals are more fundamental forces to provide a comprehensive framework separate from others and can better moderate emotional reactivity for understanding symptom development and responses to and interrupt anxious reactions within treatment and therapy. Bowen self. People can recognise more of the theory also provides guidelines choices they have for allocating energy, Bowen Theory and operating principles for time and attention. They can define life psychotherapy.

The broadest Two Fundamental Forces principles and steer by them. At lower implications for the shift from Emotional Systems levels of differentiation, individuals medical models to natural systems Chronic Anxiety are regulated more by reactivity in thinking are described throughout relationships and by reactions to each Eight Concepts Bowen’s classic collection of other. The level of differentiation papers, Family Therapy in Clinical Scale of Differentiation influences the intensity of anxiety and Practice (Bowen 1978).

Emotional Triangles sensitivity one experiences in reaction The human family has evolved Multigenerational Transmission to specific stress factors. degrees of emotional connectedness Nuclear Family Emotional Process In Bowen theory, anxiety is defined between kin, such that the biology Family Projection Process as emotional reactivity to threat, real and behaviour of each individual Emotional Cutoff or imagined. Although there may be is regulated by patterns of reacting Sibling Position differences between stress and anxiety, and relating over generations Societal Emotional Process the terms are used interchangeably within the family. Human emotion in this article. When circumstances is grounded in the automatic reactivity of all life and is responsible for the allocation of threaten the stability of the individual, his/her relationships energy toward survival of the individual organism, toward or important others, anxiety reactions shift the available relationships in the family, and toward reproduction, brain energy to fuel efforts to deal with threats. Anxiety is reflected development and learning. Calories, biochemistry, oxygen, ergs, in physiological and biochemical reactions, shifts in brain neuronal patterns, time, and attention are all aspects of energy activity (i.e., perception, thinking and feeling), behaviours and allocation. Individual metabolism, physiology and psychology relationship patterns. Each influences the other in the dynamic are regulated in relation to the stability or stress within the of emotional triangles.

Medical and mental health practitioners recognise that stress reactions and anxiety play a part in physical and psychiatric symptoms, but they are often confounded by differences in the severity and duration of symptoms, by the combinations of symptoms that often shift within the person or within the family, and by the variant responses to treatment. Bowen family systems theory provides a wider lens with which to view the interaction between factors at play in the development of symptoms and in the responses to treatment. This article describes a natural systems view of symptoms, provides an overview of the neuroscience and stress research that helps make sense of symptoms, and illustrates this perspective with a case example.

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Natural Systems View of Symptoms Emotional triangles are fundamental to human relationship systems. Reactivity between any two people is regulated in their relationship with a third person. Anxiety reactions cycle and circulate in triangles, producing patterns of closeness and distance conflict alliances focus on problems in another dependence and functioning for others, and symptoms in an individual.

With the involvement of a third person, the anxiety level decreases. It is as if the anxiety is diluted as it shifts from one to another of the three relationships in a triangle (Bowen 1978:400).

Physiological Reactivity, Anxiety & Symptom Development Physiological reactions are regulated in relationship triangles (Harrison 2014). Anxiety reactions are stirred when relationships are disturbed. In his article ‘Physical Illness and the Emotional Systems’, Michael Kerr wrote: An individual’s adaptive capacity is most strained by events that have the following types of impact: 1) threaten his emotional connections with others; 2) increase the anxious focus of others on himself; 3) increase his dependence on others; 4) increase the dependence on others on him; 5) threaten the functioning of others upon whom he is dependent; or 6) increase his level of responsibility (Kerr 1992:106).

Steve Porges, Director of University of Illinois Brain Body Center, describes the sequence of reactions to threat based upon the evolutionary lineage of the autonomic nervous systems (ANS). The human ANS incorporates three different physiological pathways that operate somewhat in sequence.

The most recently evolved mammalian vagal pathway connects facial and cranial nerves with the heart to facilitate engagement and detachment from the social environment.

Initial reactions to threat activate this mammalian vagal circuit built to quickly assess information about relationships as a reference point for stability. This is accompanied by increased corticotrophin-releasing factor (CRF) in the central nervous system. If relationships are absent or anxious, sympathetic nervous system (SNS) activity and increased adrenalin allocate oxygen and energy to fuel fight or flight responses through innervation of hollow vessels throughout the body. Skeletal muscle tension increases. Increasing levels of prolactin, oxytocin, and vasopressin fuel protection reactions. Dopamine may activate the reward system for problem-solving or risk-taking.

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When SNS strategies are ineffective and stress is sustained, the hypothalamic–pituitary axis (HPA) is activated, circulating the hormone cortisol throughout the blood stream. Cortisol prepares the organism for ongoing challenge and cycles back to the central nervous system, where it turns off activating hormones. Prolonged stress reactions disturb this homeostatic nature of cortisol (McEwen 2002, Sapolsky 1994, Calogero et al. 1988). Chronic anxiety triggers the “old vagal visceral pathway” between the brain and gut with “freeze or sleep or play dead” reactions that conserve energy and are often experienced as nausea, exhaustion and depression (Porges 2009).

Symptoms reflect the family systems’ efforts to adapt to changes that challenge familiar patterns of relating and reacting. At lower levels of differentiation, emotional fusion between family members magnifies the anxiety experienced by individuals. Health problems, social or behavioural problems, relationship disruption, psychiatric diagnoses, and other symptoms are produced when habits of reacting and patterns of adapting do not stabilise the system.

Biofeedback and neurofeedback instruments are used to measure aspects of anxiety reactions. Electrodermal Response (EDR) measures electrical activity that increased adrenalin, an indicator of SNS activity, produces at the palm. Digital Skin Temperature (DST) measures changes in temperature that occur when SNS activity produces vasoconstriction in the little vessels that carry blood and oxygen through the fingertips.

Electromyography (EMG) records skeletal muscle activity associated with tension or fatigue. Levels and patterns of physiological reactivity indicate stability, relaxation, excitement and exhaustion associated with acute and chronic anxiety (Amar et al. 1993, Rosenbaum 1989).

Neurofeedback instruments measure electrical activity produced throughout the brain using sensors placed in various locations on the scalp. Patterns of electrical activity are depicted in the strength of signals omitted, indicating the allocation of energy for emotional reactivity (brain stem and limbic system) and for cognitive or intellectual systems in the left and right hemispheres. Left hemisphere activity is associated with the survival of the individual organism, and activity from the right hemisphere is associated with relationship reactions (Zimmer 2005). Neuronal signals that have been recorded indicate what John Allman and other neuroscientists consider bridges, which allow intellectual activity to inform and moderate emotional reactions (Allman 1999, Panksepp 1998). Neurofeedback and biofeedback instruments, used in the context of psychotherapy based in Bowen theory, provide information about reactivity for the purposes of self-regulation and work on the differentiation of self.

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Psychotherapy Based in Bowen Theory Psychotherapy based in Bowen theory begins with a “survey of family fields” to establish a view of symptoms in the context of facts about the family (Bowen 1978:170-173). Interruption of anxiety begins in the first session as a family member responds to factual questions about the presenting situation and its impact on the individual’s symptoms. Biofeedback and neurofeedback instruments make visible to the client reactions that one can begin to recognise and change. Ongoing work on differentiation of self within the family is the basis for sustained change and recovery from symptoms.

A Clinical Example The woman in this example was seeking therapy to pull herself out of depression. The first session included establishing the following timeline of symptoms, while developing the family diagram and family history. (The names used here are fictional.)

Figure 1: Family Diagram Anna is the middle of three children. She became her parents’ confidant early in life. Both sets of grandparents depended on Anna’s parents for support, comfort, and some assistance. This both stabilised the family and served as a stressor with growing age.

Migraine headaches began for Anna when she was sixteen, two years after she began menstruating and the year that her father’s father died. The paternal grandfather’s death increased his widow’s dependence upon their son. Anna’s natural teenage inclination toward independence from family was met with strain on the part of her parents, as they called upon her for help when they were occupied in helping their own parents.

The year that Anna started college, she experienced abdominal pain, cramping and fatigue and was diagnosed with endometriosis. Surgery brought some relief, but gastrointestinal symptoms and migraines continued. In 1998, Anna met Enrico D the man she would later marry. Enrico was the son most involved with the care and support of his own mother, who relied heavily upon her husband and sons after the family moved from a life of some luxury in South America to the United States.

Anna’s health improved following marriage and relocation away from both families. She conceived two years after marriage and bore a son with an uncomplicated pregnancy and birth in 2009. In December 2008, Enrico’s father had a stroke that resulted in disability. His mother thus relied more upon her son and became frustrated and critical toward her 12

husband. Enrico’s father moved back to South America in July 2009 to live with his family, leaving Enrico’s mother even more dependent on her sons. Enrico began to show signs of strain.

Anna’s younger brother finished college and moved out of state for work, shifting their parents’ focus onto each other.

In 2010, dementia and physical symptoms required that Anna’s maternal grandparents move closer to her mother. Anna’s mother was occupied with their care when rumours of Anna’s father’s affair began. Anna’s migraines, severe fatigue and pain resumed in 2010, when her parents complained to her about each other and eventually separated. Anna, overwhelmed by her symptoms, depended more on her equally overwhelmed husband. The usually supportive marriage became strained. Anna became depressed.

This family history allowed Ms D, to recognise the level of anxiety in her family and patterns of reacting with conflict, distance, and dependence on others. She became aware of how much she took on stress along with responsibility for the problems or happiness of others.

Ms D could see physical reactions associated with anxiety and symptoms using F1000 biofeedback and neurofeedback instruments (Deits 2004). The baseline physiological measures met standard criteria for sustained stress and were consistent with migraine headaches, endometriosis, and ovulatory disturbance (Amar 1993, Rosenbaum 1989, Harrison 1998).

Ms D’s fingertip skin temperature indicated swings between the vagal state of collapse and SNS vasoconstriction while talking about family history and while sitting quietly. Her skin sweat response (EDR) indicated exhaustion characteristic of chronic stress. Her skeletal muscle tension also indicated swings between overreaction and exhaustion.

Ms D used Zengar Neuroptimal instruments to measure electrical activity throughout the brain, using dynamical nonlinear mathematics to analyse patterns as they occur (Brown 2012).

Information and images from these instruments make visible the patterns of reactivity associated with symptoms and with changes that occur through work on differentiation of self within the family.

Figure 2: Baseline EEG on Zengar Neuroptimal—left hemisphere and right hemisphere electrical activity from 0 Hz to 42 Hz CQ: The CAPA Quarterly

The photograph of baseline measures shows strong signals arising from emotional reactivity in the right hemisphere and weaker signals present from the left hemisphere. This neuronal pattern would be consistent with strong reactions to relationships overriding the ability to be thoughtful or to allocate energy for stability of an individual’s own metabolism or functioning.

Bowen describes and illustrates differentiation of self as the basis for change throughout Family Therapy in Clinical Practice.

[Therapy] is designed to help one or more family members to become aware of the part self plays in the automatic emotional responsiveness, to control the part self plays, and to avoid participation in the triangle moves. … Therapy also involves a slow process of differentiation between emotional and intellectual functioning and slowly increasing intellectual control over automatic emotional processes (Bowen 1978:307).

Ms D focussed on: developing the ability to see relationship triangles and how everyone was reacting within them, on recognising and managing her own reactions, on interrupting and reducing anxiety reactions, and on increasing responsibility for herself. She worked on becoming more separate in important relationships and on separating thinking from reacting. She increased contact with her extended family, gathered facts about the history and function of the family from a variety of perspectives, became a better observer, changed automatic patterns of reacting, took responsibility for self instead of relying on others, and defined her life principles and goals. These action plans and projects took place within the arena of the family and were the basis for changes that occurred over time.

Within the first few weeks of consultation, Ms D began to take more responsibility for herself. She resumed yoga, exercise, and the running of the household. She made different choices around family visits. At the same time, she began to relinquish responsibility for her parents and problems in their marriage ‘giving them back to each other’ in the context of triangles. Here is one example.

Ms D prepared for a stressful family vacation with her mother and siblings. Ordinarily, Ms D would babysit her sister’s children much of the time while her sister and her husband took time alone. This time, she instead offered to watch the children on only one of the five days. She invited her mother for walks on the beach alone to talk about the troubled marriage in the context of history and the larger family. She wrote pages of ‘who, what, where, when, how’ questions to ask in those conversations. She admitted her inability to help and encouraged her mother to talk to older and wiser members of the family. Ms D walked on the beach alone each day for time out to think. The family vacation projects went well, and Ms D returned with increased energy and fewer headaches.

Changes in physiological reactions and brain activity accompanied the changes in Ms D’s thinking and behaviour.

Measures of brain activity after the family vacation indicated stronger signals in left hemisphere activity involved in allocation of energy toward self and stability. Increased signals from intellectual activity and from the bridge between thinking and reacting at around 14 Hz are associated with increased ability to thoughtfully function for self in the midst of reacting to relationships. Biofeedback measures on the F1000 instrument also indicated decreasing chronic anxiety and exhaustion.

Figure 3: EEG on Zengar Neuroptimal after family vacation—left hemisphere and right hemisphere electrical activity from 0 Hz to 42 Hz The reality of family life remains challenging. Ms D’s parents divorced, and her mother was diagnosed with cancer two months later. Ms D conceived without medical intervention—a long-awaited pregnancy during which she declined medication and had occasional migraines. Ms D continues to work on differentiation of self during challenging times. The following email is one example.

Enrico’s brother suggested visiting this weekend. At first, I was just mad or reactive to the fact that Enrico didn’t realize company would be difficult considering what’s going on with my mom’s cancer. I thought he should have told his brother not to come. Then, I called my sister-in-law. I told her about my mom’s situation and the possibility that I may need to go help her while they were in town. She offered not to come and I told her it was fine to come but I wanted her to know what was going on. I told her the house won’t be spotless and I won’t be cooking a gourmet meal but we would enjoy their visit. She was more than understanding and offered to help. She said, if I need a break she could take [my son] for a while and they would be happy to cook one night. I was glad that she seemed to want a laid back weekend. I was worried about entertaining them and ensuring they had a great time.

I also told her I wanted her to know about my mom up front in case I wasn’t the life of the party. I didn’t want her to take it personally. I am glad we had the conversation. I feel like a load was lifted off my shoulders.

Successful efforts at differentiation of self provoke reactions to change that are challenging to most people.

Both Enrico and their son initially reacted to Ms D’s efforts by demanding increased time and attention. She described one situation where both her husband and her son wanted the computer she was using. It was not funny at the time, but she could laugh later at how quickly she was willing to stop what she was doing and focus on pleasing one or both of them. Of course, that was impossible, and both husband (continued on Page 34)

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The Mental Health of Homelessness emerged as a key policy issue for the Australian Government in 2008 with the release of the White Paper, ‘The Road Home’. This report articulated the need for more integrated service delivery, and in particular, greater investment by other sectors—such as health—to help reduce homelessness. The present paper briefly introduces the concept of homelessness and the pathways into homelessness before focussing on the relationship between homelessness and housing instability and between mental disorder and psychosocial wellbeing. The paper will also comment on ways of working therapeutically with individuals who are homeless or are experiencing housing instability.

What is Homelessness and How Many Are Affected?

Homelessness is a broad construct. It encompasses ‘rooflessness’ as well as varying forms of temporary and inadequate housing. The most commonly used definition of homelessness is that provided by Chamberlain and MacKenzie (2003) who state that a person is homeless when their housing does not meet the minimum community standard. In Australia, this equates to a one bedroom apartment with its own kitchen and bathroom. Using this definition, homelessness can be classified according to three levels: Primary homelessness includes sleeping in open spaces (e.g., street or park) or in makeshift dwellings (e.g., car) and is often referred to as ‘sleeping rough’.

Secondary homelessness includes movement between different forms of temporary accommodation such as refuges, crisis accommodation and motels, as well as temporary stays with family or friends (e.g., couch surfing).

Tertiary homelessness includes caravans and boarding houses where residents share a kitchen and/or bathroom.

Some definitions of homelessness incorporate a minimum level of safety and security of tenure. This means that even persons who are housed to the minimum community standard may still be considered homeless, if they are subjected to violence in their home or they reside in accommodation where they could be asked to leave without notice (e.g., without a lease). Homelessness can also be defined in terms of duration: transient homelessness, whereby people experience a oneoff, short-term episode of homelessness episodic or iterative homelessness, that is interrupted by periods of being housed, whether this be tenuous or stable housing (Robinson 2003), and long-term or chronic homelessness, for which there is no agreed cut-off and which has been variously defined as six months (e.g., The Mercy Foundation 2012), twelve months (e.g., Johnson & Chamberlain 2011) or two years (e.g., Farrington & Robinson 1999) of continuous homelessness.

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The exact population of homeless persons is difficult to establish because homeless persons tend to be highly transient and, as described above, homelessness can take many different forms. One source of data is the Australian census. Street counts were undertaken alongside the 2001 and 2006 census counts and algorithms applied to household counts to ascertain six categories of homeless persons: individuals sleeping rough or in improvised dwellings or tents individuals residing in supported accommodation services individuals temporarily residing with others individuals residing in boarding houses individuals residing in other temporary lodgings and individuals residing in dwellings that are severely crowded (Australian Bureau of Statistics 2012).

A total of 89,728 persons were identified as homeless in the 2006 Australian Census; this equates to a rate of 45.2 homeless persons per 10,000 persons counted. A little over half (57%) of all persons classified as homeless were male. The greatest proportion of individuals classified as homeless were in the category of severe overcrowding (35%), followed by temporary stays with other households (20%), supported accommodation (19%), boarding houses (17%), and sleeping rough (8%). A greater proportion of those sleeping rough and staying in a boarding house were male (64% and 76%, respectively); similar numbers of males and females were classified with the other forms of homelessness.

Causal Pathways and Risk of Becoming and Remaining Homeless There is no one single cause of homelessness; rather, homelessness is multi-determined and both individual and structural factors have been implicated. Individual factors may be those situations, experiences and behaviours, that cause an individual to be vulnerable (i.e., mental illness, substance use), whilst structural factors include broader societal factors, such as social housing and labour markets or restrictive legislation, which may induce or exacerbate disadvantage and vulnerability in certain populations (May 2000). This mix of causal and perpetuating factors creates a challenge for both understanding and responding to homelessness.

A number of researchers have enlisted a pathways framework to describe the interplay between structural and individual determinants of homelessness. Moreover, the interaction between the two sets of risk factors is contextualised in time and space and provides for alternative outcomes such as transitory, episodic and chronic homelessness. The pathways approach attempts to find the commonalities among individual trajectories of homelessness. Thus it is important to note that pathways are an analytical construct, a means of summarising key characteristics or attributes of a phenomenon (Clapham 2003). There will be individual differences in the experiences CQ: The CAPA Quarterly

Homeless Person s of homelessness within a prototypical pathway, and hence, individuals are unlikely to fit any one pathway exactly (Chamberlain & Johnson 2011).

Chamberlain and Johnson (2011) identified five pathways into adult homelessness among a sample of clients accessing specialist homelessness services in Melbourne. The first pathway was termed ‘housing crisis’ where homelessness was precipitated by a financial crisis, for example, a recent job loss or not being able to manage financially on a low income. The second pathway was ‘family breakdown’ and consisted of two distinct patterns: a) intimate partner violence, resulting in the abused partner (and perhaps accompanied by their children) seeking safety in a refuge; and b) relationship failure leading to one partner moving out of the family home (with the possibility of having to leave children behind). ‘Substance use’ was the third pathway identified. In this pathway, the procurement and use of alcohol or other drugs increasingly became the sole focus for that individual to the exclusion of other important activities, such as work. Additionally, the diversion of income away from essential expenses (such as rent) increased the likelihood that homelessness would ensue. The fourth pathway was labelled ‘youth to adult’ where homelessness was precipitated when a young person left the family home prematurely. This decision was sometimes driven by child maltreatment or family violence, and other times occurred because of conflict between the young person and the parent or guardian. The final pathway identified was ‘mental health’ and is differentiated into two patterns by the onset of homelessness in youth and adulthood.

In the former, the behaviour of a young person with a mental disorder overwhelmed the family’s coping capacity with the result that the young person left home. In contrast, the onset of homelessness in adulthood was precipitated by the loss of a parent who had previously protected and supported the individual with a mental illness.

Rates of mental disorder are substantially higher in the homeless population relative to the general population. For example, among a representative sample of homeless men in inner Sydney, the 12-month prevalence of alcohol use disorder was found to be 49%, mood disorder was 28%, and anxiety disorder was 22% (Teesson et al. 2004). The pathways framework clearly identifies mental disorder as a causal factor in precipitating homelessness for some people. Research showing that mental disorder precedes onset of homelessness in a substantial proportion of homeless persons supports this view (Herrman et al. 1990).

Homelessness has also been found to complicate treatment outcome among individuals with a mental illness. For example, in a Melbourne sample of patients with a psychotic disorder attending a specialist mental health service, those who had been homeless in the past 12 months were less likely to have a planned discharge from the service or to be discharged into primary care (Holmes et al. 2005). Other research has found that homelessness is associated with a higher rate of psychiatric February 2013

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hospitalisations among persons with serious mental disorder (North & Smith 1993).

It is important to note that the majority of homeless persons are not mentally ill; however, many will experience significant distress as a result of being homeless, and it is this issue upon which we next focus.

The Impact of Homelessness on Mental Health The experience of homelessness can be frightening, isolating and stressful and many individuals may benefit from mental health support regardless of whether they have a diagnosed mental disorder or not. This section explores the impact of being homeless or living in marginal or unstable housing on an individual’s psychosocial wellbeing. It is by no means an exhaustive or complete analysis of the relationship between homelessness and wellbeing; rather, it explores two paradigms for thinking about this relationship. The first paradigm is that of marginalisation and the process of social exclusion; the second is of psychological trauma.

Marginalisation and Social Exclusion Social exclusion, broadly speaking, is the process through which disadvantage arises. Factors that contribute to this process include such things as poverty, deprivation, social isolation and discrimination. Homeless persons in particular are considered to be highly marginalised and excluded from participating socially, economically and politically in mainstream society (McNaughton 2008). They are also more likely to experience problematic substance use and poor mental health, which further prevents them from accessing opportunities available to the non-disadvantaged. Given the strong evidence of the benefit of social support and meaningful employment to positive mental health (see Boardman et al. 2010), it is conceivable that the process of marginalisation and social exclusion has a negative impact on the mental health of homeless persons.

Although, there is substantial reference to marginalisation and social exclusion in the homelessness literature (Horsell 2006), there is limited examination of the specific association between the multidimensional construct of social exclusion and mental health for the homeless and how the experience of marginalisation and social exclusion may in fact be ‘internalised’ by homeless people. However, there is established evidence for other relationships within which some aspects of social exclusion (e.g., poverty and deprivation) might be considered. For example, the association between adversity and depression may bear relevance to a homeless population who, on the whole, have experienced significant adverse life events and are severely economically disadvantaged.

Adverse life events involving loss, humiliation or defeat can induce depressive symptoms (Kessler 1997). Moreover, depression appears to be strongly determined by the accumulation of adversity (Hazel et al. 2008, Felitti et al. 1998).

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Features In the context of poverty and deprivation, data from the 1999 Poverty and Social Exclusion Survey found that individuals who screened positive for depression had a higher endorsement across a number of indicators including: needing to borrow money to meet daily needs, a lack of basic necessities, dissatisfaction with housing, increased number of housing problems, and being unable to participate in leisure and social activities (Payne 2000).

The British Household Panel Study used a composite score of poverty based on annual household income, no household access to motor vehicle, inability to save on current income, fewer than four common household appliances, living in rented accommodation, living in overcrowded accommodation, and structural problems in current housing. The total poverty score as well as an item measuring financial strain, were strongly associated with continued mental health problems (measured using the General Health Questionnaire) at 12 months (Weich & Lewis 1998). Most compelling is a 30-year longitudinal study of US adults, which found chronic economic hardship to be significantly associated with depressive symptoms, hostility, lacking optimism, and poorer cognitive functioning (Lynch et al. 1997).

A lack of social supports and social isolation are commonly reported by homeless individuals (e.g., Stewart et al. 2010).

Previous research by the authors found the level of social support (measured using the MOS Social Support Survey, Sherbourne & Stewart 1991) among homeless adults in Sydney was substantially lower compared to a domiciled sample (mean score was 22.9 versus 70.1 for homeless and domiciled samples, respectively) (Conroy et al. 2011).

Substantial evidence exists, however, for the positive effect of social supports in ameliorating or moderating the impact of adversity or stressful life events on psychological wellbeing.

For example, a recent Queensland study exploring the subjective experience of wellbeing in a group of 20 homeless adults found major reported contributors to wellbeing in this group were a sense of community, positive social relationships and connecting to others (Thomas et al. 2012). A greater amount of social support has also been linked to reduced levels of homelessness episode (Zugazaga 2008).

Homeless persons are also highly stigmatised and this can contribute to feelings of social isolation and impact on an individual’s self-esteem. For example, Link and colleagues (1995) undertook a national telephone survey of US citizens and found many participants believed homelessness was typically the result of irresponsible behaviour (72%) and/or laziness (64%). Stigma and discrimination are also evident among health professionals. A US study reported that health clinics for the homeless had difficulty recruiting and retaining medical doctors, in part, because of the doctors’ own biases against working with homeless people, but also because working with the homeless population was not well respected within the medical profession (Doblin et al. 1992).

Psychological Trauma Goodman and colleagues (1991) have argued that the consequences of homelessness should be considered within the framework of psychological trauma which they defined as ‘a set of responses to extraordinary, emotionally overwhelming, and personally uncontrollable life events’. They suggest the process of becoming homeless can directly induce psychological trauma. They also suggest chronic homelessness may erode an individual’s capacity to cope, thereby inducing psychological 16

trauma, or else reinstate symptoms of psychological trauma in individuals with a prior history of trauma. We are unaware of any empirical investigation of these hypotheses, although, we do agree that trauma theory is a useful framework for understanding the impact of homelessness on mental health for a number of reasons.

Regardless of the explicit traumatogenic effect of homelessness, there is evidence to indicate homelessness may increase an individual’s exposure to traumatic events.

For example, almost half (48%) of an inner-Sydney homeless sample had been a victim of violence in the 12 months prior to being interviewed (Larney et al. 2009). This may in part be a reflection of the unsafe environments in which many homeless persons find themselves, whether this be sleeping rough, squatting, or staying in boarding houses.

Additionally, it could reflect associated lifestyle factors; for example, substance use has been associated with a higher rate of trauma exposure (Cottler et al. 2001) and is highly prevalent among homeless persons (Teesson et al. 2004). Recent work by the authors has demonstrated a re-traumatisation rate of 31.5% among a sample of men accessing specialist homelessness services in Sydney (Conroy et al. 2012). Interestingly, approximately half of those who re-experienced trauma in the 12-month follow-up period were stably housed for the entire period. The types of traumas experienced included being threatened with a weapon, witnessing someone being seriously injured or killed, and serious physical assault.

It is also conceivable that homelessness may make an individual more vulnerable to the impact of a subsequent traumatic event. This may be mediated by the high levels of psychological distress and depressive symptoms found among homeless persons, given these mental states are characterised by a sense of hopelessness and a negative world view. Negative appraisal of a traumatic experience, and negative emotions such as shame, guilt, sadness and betrayal in the aftermath of trauma, have been implicated in the persistence of posttraumatic stress symptoms (Ehlers & Clark 2000, Andrews et al. 2000). Thus, homelessness may induce cognitive schemata that render an individual more vulnerable to the traumatogenic effects of subsequent stressful events.

Finally, individuals who are homeless or experiencing housing instability have rates of lifetime trauma exposure and post-traumatic stress disorder that are substantially higher than general population estimates. Taylor and Sharpe (2008) found that trauma exposure preceded the first episode of homelessness in more than half of their adult sample. Negative beliefs about the self as hopeless, others as distrustful, and the world as unsafe are common parts of the post-traumatic response (Herman 1992). This suggests that many individuals may begin their experience of homelessness from a compromised position in terms of their mental health, which is then compounded by the experience of homelessness.

Important Considerations When Working with Homeless Persons There is no specific therapeutic approach recommended for working with persons experiencing homelessness or housing instability. However, given the above discussion on marginalisation and psychological trauma, mental health professionals working with homeless persons should be mindful of the following: CQ: The CAPA Quarterly

Accessibility: Persons who are homeless or marginally housed experience a number of barriers to accessing mental health services. First, they may find it difficult to attend appointments because of a lack of money to cover transport costs or because their time is taken up with attending support services such as Centrelink and community housing providers. Second, they might not prioritise their mental health in the midst of other urgent needs such as finding accommodation, obtaining food, or debt repayments. Third, most homeless persons are acutely aware of their appearance and find it uncomfortable to wait in general waiting areas alongside domiciled clients.

Multiple and Complex Needs: Homeless persons are often described as having complex needs and this is true to some extent. For example, poor nutrition, head injuries and substance use contribute to high rates of cognitive impairment in the homeless population, and this can complicate treatment. Additionally, the physical health of homeless persons may be quite poor, and this can contribute to the client’s overall mental health status. Much of the complexity in working with these individuals, however, is related to the lack of resources concomitant with being homeless rather than to the particular mental health issues with which they may present. Therapists need to be creative in the strategies they use with clients, for example, finding a quiet personal space for meditation.

Resilience: Homeless persons survive despite the incredible stressors they endure. The therapeutic process can assist clients to recognise their strengths, build their capacity to cope with their current circumstances, identify the issues that may have contributed to their episode of homelessness, and restore self-esteem.

Conclusion Homeless persons are a highly marginalised and heterogeneous population. The brief overview here of what homelessness is and how homelessness comes about and the discussion—in reference to the paradigms of social exclusion and psychological trauma—of the relationship between mental health and homelessness can help to inform therapists about how to best work with clients who are experiencing homelessness or housing instability.

References

Andrews, B, Brewin, C, Rose, S and Kirk, M 2000, ‘Predicting PTSD Symptoms in Victims of Violent Crime: The Role of Shame, Anger and Childhood Abuse’, Journal of Abnormal Psychology, 109: 69-73 Australian Bureau of Statistics 2012, Census of Population and Housing: Estimating Homelessness, 2006, Canberra: ABS Boardman, J, Currie, A, Killaspy, H and Mezey, G 2010, Social Inclusion and Mental Health, London: RCPsych Publications Chamberlain, C and Johnson, G 2011, ‘Pathways into Adult Homelessness’, Journal of Sociology, 1-18 Clapham, D 2003, ‘Pathways Approaches to Homelessness Research’, Journal of Community & Applied Social Psychology, 13: 119-127 Conroy, E, Burns, L, Di Nicola, K and Flatau, P 2012, ‘Trauma Exposure and Posttraumatic Stress Symptoms Among Homeless Men Accessing Integrated Support in Sydney, Australia’, International Society for Traumatic Stress Studies 28th Annual Meeting, Los Angeles: ISTSS Conroy, E, Burns, L and Wilson, S 2011, ‘Alcohol Use Disorder and Cognitive Impairment Among Older Homeless Persons: Implications for Service Delivery’, report prepared for the Foundation for Alcohol Research & Education (FARE) Cottler, L, Nishith, P and Compton, W 2001, ‘Gender Differences in Risk Factors for Trauma Exposure and Post-Traumatic Stress Disorder Among Inner-City Drug Abusers in and Out of Treatment’, Comprehensive Psychiatry, 42: 111-117 Doblin, BH, Gelberg, L and Freeman, HE 1992, ‘Patient Care and Professional Staffing Patterns in McKinney Act Clinics Providing Primary Care to the Homeless’, JAMA, 267: 698-701 Ehlers, A and Clark, D 2000, ‘A Cognitive Model of Posttraumatic Stress Disorder’, Behaviour Resarch and Therapy, 38: 319-345 Farrington, A and Robinson, WP 1999, ‘Homelessness and Strategies of Identity Maintenance: A Participant Observation Study’, Journal of Community & Applied Social Psychology, 9: 175-194

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Felitti, V, Anda, R, Nordenberg, D, Williamson, D, Spitz, A, Edwards, V, Koss, M and Marks, J 1998, ‘Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study’, American Journal of Preventive Medicine, 14: 245-258 Goodman, L, Saxe, L and Harvey, M 1991, ‘Homelessness as a Psychological Trauma,’ American Psychologist, 46: 1219-1225 Hazel, N, Hammen, C, Brennan, P and Najman, J 2008, ‘Early Childhood Adversity and Adolescent Depression: The Mediating Role of Continued Stress’, Psychological Medicine, 38: 581-589 Herman, J 1992, Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror, New York: Basic Books Herrman, HE, McGorry, PD and Bennent, PA 1990, ‘Age and Severe Mental Disorders in Homeless and Disaffilitated People in Inner Melbourne’, Medical Journal of Australia, 153: 197-205 Holmes, AC, Hodge, MA, Bradley, G, Bluhm, A, Hodges, J, Didio, L and Markulev, N, 2005, ‘Accommodation History and Continuity of Care in Patients with Psychosis’, Aust N Z J Psychiatry, 39: 175-9 Horsell, C 2006, ‘Homelessness and Social Exclusion: A Foucaldian Perspective for Social Workers’, Australian Social Work, 59: 213-225 Johnson, G and Chamberlain, C 2011, ‘Are the Homeless Mentally Ill?’, Australian Journal of Social Issues, 46: 29-48 Kessler, R 1997, ‘The Effects of Stressful Life Events on Depression’, Annual Review of Psychology, 48: 191-214 Larney, S, Conroy, E, Mills, KL, Burns, L and Teesson, M 2009, ‘Factors Associated with Violent Victimisation Among Homeless Adults in Sydney, Australia’, Aust N Z J Public Health, 33: 347-51 Link, BG, Sschwartz, R, Moore, R, Phelan, J, Struening, E and Stueve, A 1995, ‘Public Knowledge, Attitudes, and Beliefs about Homeless People: Evidence for Compassion Fatigue’, American Journal of Community Psychology, 23: 533-555 Lynch, JW, Kaplan, GA and Shema, SJ 1997, ‘Cumulative Impact of Sustained Economic Hardship on Physical, Cognitive, Psychological and Social Functioning’, New England Journal of Medicine, 337: 1889-1895 May, J 2000, ‘Housing Histories and Homeless Careers: A Biographical Approach’, Housing Studies, 15: 613-638 McNaughton, C 2008, ‘Transitions Through Homelessness, Substance Use and the Effect of Material Marginalization and Psychological Trauma’, Drugs: Education, Prevention & Policy, 15: 177-188 North, C and Smith, E 1993, ‘A Systematic Study of Mental Health Services Utilization by Homeless Men and Women’, Social Psychiatry and Psychiatric Epidemiology, 28: 77-83 Payne, S 2000, ‘Working Paper No. 5: Poverty, Social Exclusion and Mental Health’, Bristol: Townsend Centre for International Poverty Research, University of Bristol Robinson, C 2003, ‘Understanding Iterative Homelessness: The Case of People with Mental Disorders’, AHURI Final Report, Sydney: AHURI UNSW-UWS Research Centre Sherbourne, C and Stewart, A 1991, ‘The MOS Social Support Survey’, Social Science Medicine, 32: 705-714 Stewart, M, Reutter, L, Letoumeau, N, Nakwarimba, E and Hungler, K 2010, ‘Supporting Homeless Youth: Perspectives and Preferences’, Journal of Poverty, 14: 145-165 Taylor, KM and Sharpe, L 2008, ‘Trauma and Post-Traumatic Stress Disorder Among Homeless Adults in Sydney’, Aust N Z J Psychiatry, 42: 206-13 Teeson, M, Hodder, T and Buhrich, N 2004, ‘Psychiatric Disorders in Homeless Men and Women in Inner Sydney’, Aust N Z J Psychiatry, 38: 162-8 The Mercy Foundation, 2012, Homelessness [Online], Sydney, Viewed on 10/10/12 at http://www.mercyfoundation.com.au/homelessness/index.cfm?loadref=21 Thomas, Y, Gray, M and McGinty, S 2012, ‘An Exploration of Subjective Wellbeing Among People Experiencing Homelessness: A Strengths-Based Approach’, Social Work in Health Care, 51: 780-797 Weigh, S and Lewis, G 1998, ‘Poverty, Unemployment and Common Mental Disorders: Population Based Cohort Study’, British Medical Journal, 317: 115-119 Zugazaga, C 2008, ‘Families in Society’, The Journal of Contemporary Social Services, 89: 448-456

Elizabeth Conroy, BSc (Psych), Hons, PhD, is a Research Fellow at the Centre for Health Research, University of Western Sydney. Elizabeth conducts research in the area of homelessness and mental health; in particular, she is involved in a number of evaluations of service delivery models aimed at providing integrated support for individuals who are homeless and who also have substance use and/or other mental disorders.

Elizabeth is also a registered psychologist and has previously worked clinically with the substance use treatment population and now provides counselling to asylum seekers living in the community.

Monica Thielking, BA (Youth Affairs, Psych), Hons, PhD is a psychologist and researcher currently working as a Research Fellow at the Swinburne Institute for Social Research. Monica leads a number of research projects related to early intervention, youth mental health and wellbeing, homelessness and integrated service delivery for homeless and at risk clients. Monica is currently a CI on: a large national study on how student support services are delivered in schools around Australia, a national project estimating the economic and social costs of youth homelessness, and a research and development project testing a new model of service delivery aimed at reducing youth homelessness in Geelong. Monica chairs the APS Psychologists in Schools Interest Group and is a member of the APS Psychologists in Schools Reference Group.

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Features

Breaking the Silence and Singing Kirstin Robertson-Gillam, Michael Atherton and Leon Petchkovsky

Many people have desperate and unique life histories. Many seek psychological counselling in order to free themselves from their traumatic memories (Cardinal, 1992). This article defines and describes how individual vocal improvisation and a choir support program (developed by the lead author) can enhance existing practices for addressing psychological trauma. The efficacy of these creative approaches are described and supported by underlying theories, a pivotal case study and research in this area.

Music is present in all cultures and, in the West, it is considered to be an art form. Music can engage many areas in the brain holistically. For instance, Koelsch (2009:374) asserted that music: engages sensory processes, attention, memory-related processes, ‘mirror neuron system’ activity, multisensory integration, activity changes in core areas of emotional processing ... and social cognition.

The traumatised part of our psyche is often fragmented by early childhood experiences (Austin 2001). We build a variety of defence mechanisms in order to protect the most vulnerable parts, which may have been damaged and fragmented at a time when we could not articulate our needs or control our circumstances. The quality of the mother-child relationship in the early stages of life affects how we relate to others throughout our lives. The musical language of ‘motherese’, which includes interactions like crooning, singing, rocking and swaying, plays a crucial role in cognitive development and emotional regulation (Warnock 2011). An early study showed infants preferred maternal infant-directed speech over adult-directed speech that also used unfamiliar female voices (Cooper et al. 1997), while another study (Trainor et al. 1992) found that motherese holds an important role in the development of affect regulation. Chang and Thompson (2011) demonstrated that infants’ whines and cries as well as motherese hold important evolutionary benefits for infant survival. These studies support the importance of the mutual exchange of vocalisations of mother or other caregiver and infant in the child’s ongoing emotional regulation and cognitive development, which may have implications for the child’s later life (Marwick & Murray 2009).

Mithen (2005) postulated that vocal communication— initially in the form of meaningful grunts, groans and shouts—most likely preceded language, affording the early Neanderthals an evolutionary advantage. It could be speculated that motherese may hark back to these earlier times before human language developed. The usefulness of language evolution has had many purposes. Perhaps one of the earliest 18

reasons for its evolutionary development could have been as a form of vocal grooming—as opposed to physical grooming—in order to expedite a more efficient way of multi-tasking survival activities such as plant gathering (Aiello & Dunbar 1993).

According to McGilchrist (2010), music, as a poetic and exaggerated form of communication, speaks to us rather than about us and has an ‘I-thou’ existence in the psyche, rather than an ‘I-it’ presence. When music is used with positive, healing intentions and we sing to and with each other, in a spirit of mutuality, it is possible to transcend the mundane side of human nature.

Hodges (2000:2-3) asserted that music “is a species-specific trait of humankind” and that “a musical brain is the birthright of all human beings”. Hodges further contended that “all members of our society, from cradle to grave, stand to benefit from being musically involved”. This latter assertion has been supported many times from the lead author’s own personal experience as a music psychotherapist. Furthermore, young children who are sung to and encouraged to sing are more likely to develop good pitch and auditory fitness, which have a role in shaping individual development (Kraus & Chankrasekaran 2010).

In the later stage of life, when older people have strokes with resulting damage to their speech centres, melodic intonation therapy (MIT), which emphasises the musical aspects of language, is in many cases successful for speech recovery in people with aphasia following stroke. A study by Shioda et al.

(2009) validated this approach when they combined the use of Transcranial DC Stimulation to the brain with MIT and found that the sensorimotor network for articulation in the right hemisphere was enhanced, thereby compensating for damaged left-hemisphere speech centres following a stroke.

Individual vocal improvisation as part of a choir program with a counselling framework as described by Robertson-Gillam (2008a) can complement existing therapeutic interventions and engage the brain across many functional areas—in both right and left hemispheres as described by McGilchrist (2010).

Choir Therapy Studies Song lyrics, like poetic language, are able to express, resonate with and contain traumas that are buried deep within the psyche and are often not expressed in normal speech. A weekly choir support program involving singing, exercises, discussion and mindfulness meditation can divert constant ruminations which maintain depressed states. Newham (1999:71) asserted that even though we cannot rewrite our traumatic history, singing “tricks history by succumbing to its immovable presence. … The song remains the same … sung a million times CQ: The CAPA Quarterly

Out the Pain:

Voice Work for Traumatised Clients

by a million people�. When it is sung by so many, it becomes a shared phenomenon. Many people have reported to the lead author that this somehow eases and validates their trauma.

Clift and Hancox (2001, 2010) found that singing promoted physical and emotional wellbeing, improved lung capacity and increased energy levels. Additionally, Cohen (2006) demonstrated that choir singing improved general health in seniors with less need for medication, significantly fewer falls, diminished depression and loneliness, and increased morale.

From a biological perspective, choir singing of Mozart’s Requiem (Kreutz 2004) was found to enhance the immune system, and from a sociological perspective, Tonneijck et al.

(2008:179) found that choir singing as a leisure activity could achieve wholeness through challenge.

Music and speech are linked as vehicles of emotional self expression. The perception of emotion as expressed in speech is a fundamental requirement for meaningful communication. Deficiencies in this area are found in socially isolating disorders such as autism and also in subclinical and clinical depression (Strait et al. 2009). Musical experience was found to enhance the perception of emotion in speech, thereby enhancing communication and social interactions (Strait et al. 2009). Further brain studies found that music has a positive effect on the frontal EEG asymmetry of mothers with post-partum blues (Im & Shin 2011), and Morgan et al. (2010) found that music listening can decrease beta brain activity during a psychotic schizophrenic episode, increasing cognitive functions while, at the same time, decreasing hyperarousal. The most recent study (Fachner et al. 2012) found that music improvisation can reduce anxiety in depressed clients by modulating fronto-temporal activity in Rest-EEG. Brain asymmetry is known to exist in depressed and anxious states (Kropotov 2009), and these studies support the use of music to create more symmetry and reduce depressive and anxietal conditions.

The choir support program encourages verbal discussion and journalling. A study by Ochsner et al. (2002) supports this part of the choir program. These researchers found that people who use words, either written or spoken, to describe their internal states of emotion and perception, are more flexible and capable of regulating their emotions in a more adaptive manner.

The choir support program also includes mindfulness meditation (Siegel 2007), aiming to relax and promote positive thinking. From a cognitive perspective, a study by Genevsky et al. (2010) demonstrated significant improvements in working memory, verbal learning and global cognition in schizophrenics using a cognitive remedial approach. This February 2013

study gives support to the use of the cognitive aspect of mindfulness meditation within the choir program. From a meditation perspective, Cahn and Polich (2009), using the P3a event-related brain potentials, found that the state of meditation can reduce cognitive and emotional reactivity with greater attention to tasks. Furthermore, Kingston et al. (2007) used mindfulness-based cognitive therapy and found that it had a marked effect on residual depressive symptoms by diverting excessive ruminations. These studies give support for the inclusion of a mindfulness meditation segment, which includes positive affirmations as part of the choir support program.

The lead author has been researching and developing the effectiveness of the choir support program with elderly and middle aged adults for the past ten years. In 2003, she formed her first choir support group (N=16) with residential elderly people who demonstrated social isolation and depressive symptoms. The combination of singing, verbal discussion and mindfulness meditation proved highly beneficial as regular surveys demonstrated. This choir grew into a close community in which many life events were celebrated and performed, including deaths of members, birthdays and performances in the wider community.

In 2005, the lead author embarked on a Masters program (Robertson-Gillam 2008a), which included a pilot study (N=29) researching the choir support program with depressed elderly people in residential care. The choir support program was compared to a reminiscence group and both were compared to a control group that received ordinary care. A positive trend towards decreasing depression was found. This pilot was replicated in a randomised controlled trial (N=41), at another residential facility, involving depressed people with severe dementia (Robertson-Gillam 2008b). Cognitive functioning (group mean=13.6/30) was assessed using the Mini Mental State Examination (Folstein et al. 1975).

Depressive symptoms were assessed using the Cornell Scale for Depression in Dementia (Alexopoulos et al. 1988). Levels of responsiveness were measured by observation and video following each of the fifteen sessions over seven weeks. Results showed a significant drop in depression, particularly in the choir program group (p<0.001; power = 1.00) and significant positive trends in levels of responsiveness such as expression of feelings (p<0.013, power 73%), positive mood changes (p<0.010, power 77%) and engagement in sessions (p<0.015, power 71%).

In 2010, the lead author conducted a mixed methods, controlled trial (N=32) with depressed, middle-aged community dwelling adults, as the field work for a doctorate.

19

Features

This trial compared the choir support program to a waitlist control group who lived their lives as normal. A pilot study using quantitative electroencephalography (QEEG) was also conducted by the first and third authors, within the larger study, with nine participants who were randomly allocated from the choir program group. The Beck Depression Inventory II (Beck et al. 1996) was used along with the Spirituality Index of Wellbeing (Daaleman & Frey 2004) and the WHO-QOL-BREF (Skevington 2004) for quality of life.

Results showed a significant drop in depression (p< 0.001, power 98.0%) and an increase in wellness (p< 0.013, power 72.6%). The weekly choir surveys showed significant results in two areas: increased comfort with singing (p< 0.01) and enjoyment of social interactions (p< 0.01). Before the choir program intervention, the QEEG readings showed a state of chronic hyper-arousal and brain asymmetry, whereas, after the choir intervention, the amount of alpha activity was more widespread frontally (Fp1) with a significantly lower novel response in the P3a Novelty Event Related Potentials (ERP) at p< 0.05. This is considered to be consistent with the reduction of depression (Budzinski et al. 2009).

Comments from choir participants supported these results: “I didn’t know I had a voice”; “Singing speeds up getting to know people”; “Singing has given me power”; and, “I feel happy again.”

These choir studies focussed on the choir support program as a whole, rather than individual segments of it. Therefore, it is unclear whether one segment i.e., mindfulness meditation versus singing the songs, was more effective than others.

Choir work as a support program offers a creative outlet for those who have been participating in regular counselling for various forms of mental health issues. Each participant in the program is either self referred or has been referred from another clinician or medical practitioner. Music primarily accesses the emotions, so that even though the vocal work described here also involves verbal and written expression, care must be taken to ensure that the emotional content of vocal work does not exacerbate existing traumatic memories without adequate processing and support by the clinician.

Ullrich and Lutgendorf (2002) found that those who focussed by journalling only on the negative emotions that were associated with traumatic events, were more at risk of developing severe mental health symptoms than those who used cognitive processing methods.

On the other hand, if carefully administered by the clinician, a group singing program has restorative benefits that also enable access to painful, frozen feelings, creating something beautiful with new positive perceptions and giving hope for healing (Austin 2001).

The choir support program was developed over the past ten years by the lead author while working as a registered music psychotherapist and clinician. Each segment within the choir program has therapeutic value: Silence and breath awareness slow the heart rate and calm the nervous system (Austin 2001).

Mindfulness meditation aims to divert negative ruminations and induce relaxation (Siegel 2007).

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Singing exercises, involving scales, arpeggios, long and short held notes, staccato, breath control, musical dynamics and vowel/consonant exercises, often engage subjects in humorous and enjoyable games, which lighten negative moods and encourage mastery of a new skill.

Group vocal improvisation encourages spontaneous and creative expression, which aims to increase vocal confidence (Austin 2001).

Learning to sing both well known and new songs, improves singing abilities for later performance opportunities and together forms the core of the support group work. This social learning activity increases enjoyment, self esteem and confidence (Davis et al. 2005). Care must be taken when choosing songs for traumatised participants, as some songs can stimulate traumatic memories. Furthermore, choir support work involves empathic listening, rephrasing of words, reflection and group discussion, which are all important components of this section of the choir support program (Davis et al. 2005).

Singing the same concluding song each week marks the end of choir practice and aims to produce a sense of stability and satisfaction. The structure of the program increases creativity, motivation and self confidence for all age groups, leading to healthy emotional and physical growth (Robertson-Gillam 2008b, 2011).

Vocal Improvisation for Traumatised Clients Winnicott (1971) believed that therapy is about two or more people playing together, promoting enjoyment, motivation, a sense of coherence and belongingness. Bowlby (1979) postulated that patients who had traumatic early childhood histories demonstrated symptoms of compromised attachment disorder, leading to mental health problems later in life. Cozolino (2008) also asserted that childhood abuse and neglect can inhibit normal social development, leading to behavioural and learning disorders. Vocal improvisation provides a safe space for early traumas to surface and be explored (Austin 2001).

Laing (1960:139) asserted that a “sense of identity requires the existence of another by whom one is known and a conjunction of this other person’s recognition of one’s self with self-recognition”. By building relationships through singing as well as talking, a sense of meaning and purpose can be experienced (Newham 1999).

The nature of creativity is central to vocal improvisation.

Spinelli (2001:139) asserted that “acts of creation ... retain an inherent ‘forwardness towards unconcealment’ that permits the exploration of novel, interrelational possibilities”.

Singing through the memories of trauma can give a new perspective on the hidden and repressed issues that often lie beneath the words.

Austin (2001:141) asserted that “vocal improvisation facilitates spontaneous and emotional connection to self and other ... creating a flow ... a safe space where music, words and silence can play together and self-expression can flourish”.

CQ: The CAPA Quarterly

The stages as designed by the lead author within a vocal improvisation session are: talking therapy to identify significant issues relating the issue to other aspects of the person’s life that may be significant, including the identification of the client’s narrative with mythological stories that may help broaden understanding of an issue using vocalisations between therapist and client in a ‘voice-on-voice’ interaction (in some cases accompanied by an instrument) and bringing it to conscious awareness drawing the symbology of the experience by the client, who names, dates and owns it talking about the experience with the therapist listening to the recording of the improvisation, and journalling personal reflections and experiences for the next session.

Vocal improvisation may not occur at every session, but often is intermittent throughout the course of the therapeutic journey. The following case study conducted by the lead author illustrates the above strategies.

A Clinical Example Jane (not her real name) had experienced a severe psychotic breakdown which, she said, robbed her of eight years of her life. She was 54 years old and in a withdrawn and almost mute state in an aged care hostel when she began treatment with the lead author. During her initial visit, she said that she felt only half-human because she could no longer cry. As her words were so non-descriptive, the lead author engaged her in a musical and vocal interaction. She was then asked to draw how she felt. She drew a rainbow around the outside of a circle but left the middle empty, about which she expressed some concern. She named her drawing ‘Empty’ and dated it herself.

After this, she was encouraged to engage in a drumming improvisation when she spontaneously cried. It was the first time she had cried in eight years.

She began journalling, going on daily walks and having weekly counselling sessions that were psychodynamically oriented. A mythological story, Vasalisa the Wise—the girl with the doll in her pocket—was shared with Jane. This age-old story speaks of learning to listen to intuition and to building a more trusting and loving relationship with the inner self, symbolised by the doll. Jane was given a small doll to take with her on her walks and instructed to touch the doll so she could learn to symbolically build trust in her own intuition. The doll became a transitional object for Jane as she gradually began to trust her own intuition, demonstrating more awareness and self confidence (Winnicott 1971).

After six months, Jane began vocal improvisation which allowed for deeper insights to emerge (Austin 2001). One significant session revealed that she had never felt heard or noticed. Jane expressed this inner turmoil and pain through singing together. She felt that she had found her voice for the first time. Initially, Jane’s voice quavered and gravelled in the low notes uttering only short staccato cries as she held the notes tentatively, hardly daring to release them. The lead author’s

voice met hers harmonically in the higher treble registers with reassuring legato vocal notes (Austin 2001) that gently weaved around hers, providing the holding space she needed for true self expression. As her confidence grew, Jane began to explore the treble and soprano ranges with longer held utterances and a determination that was palpable. Her song finished triumphantly in the higher notes (C/E4), while the lead author sang and ‘held’ the space (G/C3) in the safety and security of the lower tenor registers. The structure of the two tones (G/C) provided a predictable, secure container for Jane’s frozen inner turmoil and pain (Austin 2001). Following the session, Jane then did her own drawing. She drew a yellow background superimposed with squiggly circles symbolising the creativity of a young child. Jane named her picture, ‘I Will be Heard’.

Afterwards, she said she felt more confident in expressing her feelings. Her drawing demonstrated no empty inner space and was reminiscent of early childhood expression.

The most significant session was eight months after beginning treatment, when Jane brought to conscious awareness a deeply traumatic memory of a psychotic breakdown—of being airlifted to hospital, afraid and totally withdrawn. This time, she was encouraged to use words in her singing along with instrumental improvisation. During the verbal discussion beforehand, Jane expressed how she had ‘no voice’, which became the turning point for breaking through her ego defence barriers and facing the trauma that lay within. She began by drumming loudly and angrily, and was accompanied on the piano, using the holding chords of C4 and G4, which gave space for her drumming expression and provided a “secure musical and psychological container” for her emotional expression (Austin 2001:7). She repeatedly sang: “I have no voice”, “I have no mouth”, “—— controls me”, “I am disappearing”, while she beat loudly on the tympani drum and sobbed. The lead author mirrored her words while playing the piano and extemporising when appropriate. This gave validation to Jane’s grief, anger and pain. She finished curled up in a semi-foetal position on the floor, singing in a plaintive, high-pitched, child-like voice. The lead author continued to support her with her voice, providing an harmonic and rhythmic base around the two chords on the piano (Austin 2001:9). During her drawing time, Jane angrily scribbled with black and then purple crayon. It was as if she continued to release more pain during this process. Jane named her depiction of her pivotal session, ‘No Voice’.

Jane’s psychological growth continued over the next few years through vocal improvisation and talking therapy, which involved psychodynamic, cognitive and existential approaches. She now lives in her own flat and advocates for mental health consumers.

Conclusion Vocal improvisation and choir support programs can offer creative approaches alongside other therapeutic modalities. Brain studies demonstrate that vocal therapies can engage the brain holistically, creating new neural pathways towards better health and wellbeing (Morgan et al. 2010, Im & Shin 2011, Fachner et al. 2012). Using music within an existing counselling or psychotherapy practice can enliven and enhance the therapeutic relationship, adding a new perspective when dealing with traumatised clients. (continued on Page 35)

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Features

Maternal Depression & Anxiety Jane Kohlhoff and Bryanne Barnett

The transition to parenthood, especially with the first child, is physiologically, psychologically and socially stressful. Although such a significant developmental stage may be associated with joy, satisfaction and personal growth, mental disorders are common at this time. They include a range of difficulties from schizophrenia and bipolar affective disorder, through various depressive and anxiety disorders, eating disorders and substance misuse, to personality disorders. In this article, we will focus on the commonest complications for women in the perinatal period (defined as from conception to twelve months postpartum), namely, depression and anxiety.

Prevalence The prevalence of maternal depression is estimated to be 7–13% during pregnancy (2–6% of which meet diagnostic criteria for major depression) (Gavin et al. 2005) and 10–13% during the postnatal period (Cox & Barton 2010). Rates vary considerably depending on the situation of the women being studied, with higher rates evident in disadvantaged populations (Fisher et al.

2012). Despite an historical focus on perinatal depression, there has been increasing acknowledgement of the prominence of perinatal anxiety. Given that even in 2012 there is no guarantee that perinatal complications will not arise, a degree of anxiety and ambivalence should be expected. (Fortunately, ordinary ‘goodenough’ maternity care will always take this into account.) Many women, however, report exacerbation of long-standing (trait) anxiety during pregnancy, which may reach clinical significance.

Some women experience a dramatic increase in anxiety after the child is born, manifested sometimes as panic attacks, obsessive compulsive disorder traits, excessive worry or phobias. Posttraumatic stress disorder can also develop after stressful medical, surgical, obstetric and gynaecological procedures, and after labour (Phillips et al. 2007, Phillips et al. 2009, Ross & McLean 2006). As is the case at other times of life, perinatal depression and anxiety often co-occur (Stuart et al. 1998, Wenzel et al.

2005). In a recent Australian study of over 1500 women assessed during late pregnancy and then again throughout the first eight months postpartum, 20.4% had an anxiety disorder (two-thirds of whom also had comorbid depression). Almost 40% of those who had a major depressive episode also had a comorbid anxiety disorder (Austin et al. 2010).

Risk Factors The primary risk factors for poor perinatal mental health have been identified to include: a lack of social support (especially from a partner and/or mother) recent life stresses (e.g., unemployment, house move, illness or death in the family, financial constraints) 22

Case Study Jessica, aged 26, at 24 weeks’ gestation attended the booking-in clinic at her local maternity hospital. The standard comprehensive assessment, including psychosocial assessment and depression screening, revealed several current and potential problems. This was her fourth pregnancy and followed one stillbirth (a daughter), one healthy baby (a son, Andy, who was now five) and a late miscarriage. Jessica’s first pregnancy had occurred at age 16, with a boy of the same age who then subsequently disappeared from the scene. She was not sure about wanting the new baby and was fearful of another miscarriage or stillbirth, but said a termination was out of the question. She noted that her partner, Harry, aged 34, was supportive, but worried that she was pregnant again. She claimed she had been on an oral contraceptive pill and had not forgotten to take it.

When asked about her mental health, Jessica gave a history of depression following each pregnancy with no treatment. Her EPDS score indicated a probable major depressive episode, and she gave a positive response to the item enquiring about self-harm.

When asked further about this she indicated no suicidal plans, but said she would run away if she had the energy—and that she’d thought of driving over the side of a bridge near her home. She then said there was no way she would leave Andy, although he was a great worry to her and sometimes hard to manage. Andy had started school but seemed to be off sick much of the time.

The weekly multidisciplinary meeting resulted in Jessica’s referral to the Midwives Clinic to ensure continuity and careful monitoring. Upon her first visit to the clinic, the midwife confirmed Jessica’s ambivalence toward the current pregnancy and asked about the miscarriages and the stillbirth. Jessica said she remembered feeling “frozen” when these events occurred and could give no details about the stillbirth. She said that the cause of the baby girl’s death was not known and that “no one ever offered any help”. Later in the discussion, Jessica conceded that she had been offered antidepressants in the past but was unwilling to take them. She said she felt miserable and empty and indeed always had, and so could not see how medication could fix that. The midwife arranged to see her regularly and suggested she attend the nearby Perinatal and Infant Mental Health Service (PIMHS) for additional support.

The PIMHS assessment confirmed the above history. Jessica was clearly not managing. She looked older than her stated age, unwell and exhausted from lack of sleep. She was often slow to answer questions, seeming quite distracted. She reported being unable to maintain her usual high standards at home and was very self-critical about this. She was tense and wary. By the end of the

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in the Perinatal Period:

Predictors, Impacts & Treatments

session, however, she was more settled and seemed prepared to attend the clinic provided no-one gave her a psychiatric diagnosis or insisted she should take medication. The therapist thought medication would be helpful as Jessica met criteria for both Major Depression and Generalised Anxiety Disorder, but agreed to leave this for a later discussion provided that Jessica attended regularly. This agreement seemed key to the therapeutic alliance that subsequently developed.

Jessica agreed to attend weekly. After several sessions, she seemed crestfallen and worried about remembering so little of her life and agreed that the therapist should conduct a formal Adult Attachment Interview to help with this (Steele & Steele 2008). Among many important aspects revealed by this set of questions were several unresolved traumatic events. Her mother had been mentally ill during Jessica’s childhood, and was admitted to hospital after Jessica’s birth. She had also suffered several miscarriages before conceiving Jessica. Then there was a complication during the pregnancy with Jessica, and her mother was apparently told her baby might not live. None of these difficulties had ever been discussed in the family. Jessica’s father, whose name, like her son, was Andrew, died suddenly when she was about ten years old. During the interview, Jessica contradicted herself on a number of occasions when discussing her age at the time of her father’s death. She was also vague about how and where he had died. She indicated they were very close and talked about him in the present tense. Jessica’s mother, older sister and brother were all still alive, but her current relationships with them were poor and distant, even though her mother lived in an adjacent suburb. Jessica seemed to blame her mother for the death of her father. “He worked himself to death because Mum was not able to look after things properly on the home-front and never worked outside the home to earn any money”, she said, adding: “I did my best to keep things in order always, especially after my brother and sister left home.”

Jessica’s education was limited by the frequent need to stay home from school, apparently because her mother was unwell, and she bitterly regretted this; again blaming her mother.

Harry was invited to attend some sessions, and the therapist also asked the couple to bring Andy on one occasion. With Harry’s encouragement, Jessica agreed to take antidepressant medication and soon benefitted from this. Strategies for supporting both his wife and his son were discussed with Harry. With Jessica’s permission, various medical records were obtained so that the previous obstetric problems could be reviewed. Consultation with one of the hospital’s obstetricians was arranged, and Harry requested that he be present. As time (continued on Page 24) February 2013

unresolved loss and/or trauma (including migration) reproductive complications and losses (e.g., infertility, miscarriages, terminations, sick baby, stillbirth, etc.) domestic violence chronic medical conditions (e.g., over and underactive thyroid, pre-existing hypertension) minority group status cigarettes, alcohol or other drug use, and previous mental health problems.

All of these variables constitute or are the result of ‘psychosocial stress’ and are likely to interact with genetic and epigenetic factors. Low socio-economic status and a lack of education are also prominent factors, but perinatal mood and anxiety disorders are no respecter of class, with many professional women also experiencing problems.

Impact The negative impacts of maternal perinatal depression and anxiety can be extensive—affecting not only sufferers themselves, but also partners, families and children. Maternal depression and anxiety can interfere with confidence, enjoyment and bonding with the infant. They can also be debilitating and chronic, persisting throughout the first postnatal year, recurring in subsequent years and after subsequent births (Cooper & Murray 1995, 1998, Philipps & O’Hara 1991). In extreme cases, maternal death by suicide is also a risk (Lewis 2007). Fathers too may experience psychological problems, especially if their wives are unwell. The prevalence of perinatal paternal depression, according to one meta-analysis, was 10.4%, with the highest prevalence occurring between threeand six-months postpartum (Paulson & Bazemore 2010).

Perhaps of greatest concern is the known links between maternal perinatal mental illness and child outcomes.

Although the placenta has an enzyme to protect the foetus against the excess cortisol produced by the HPA-axis under high stress and anxiety conditions, mothers with high trait anxiety and depression are known to have lower levels of this enzyme. Research has shown maternal antenatal anxiety and stress to be associated with a range of negative child outcomes including: compromised obstetric, foetal and neonatal outcomes (Alder et al. 2007) difficult infant temperament and sleep disturbance (Austin et al. 2005) cognitive, emotional and behavioural difficulties (O’Connor et al. 2002, 2003) 23

Features Attention Deficit and Hyperactivity Disorder (ADHD) and anxiety (Van den Bergh & Marcoen 2004) language delay (Laplante et al. 2004), and impulsivity and impaired cognitive functioning in adolescence (Van den Bergh et al. 2005).

It is important to note, however, that the effects of antenatal stress on child outcomes are known to be mediated by postnatal parenting sensitivity and infant attachment (Bergman et al. 2008, 2010, Grant et al. 2010).

Indeed, once born, the quality of care-giving plays an extremely important role in a child’s development. Healthy development is optimised by care-giving characterised by responsiveness, sensitivity, interactional synchrony, warmth and involvement (Crockenberg & Leerkes 1993). Research, however, has shown mothers suffering from depression and/ or anxiety to be less sensitive to infant cues and to show less warmth and positivity in their interactions with their child (Moore et al. 2004, Seifer & Dickstein 1993). This, in turn, is thought to influence the neurological systems in the infant that regulate fear and stress responses (Fox & Hane 2008, Weinstock 2008). Functional neuro-imaging studies of infants whose mothers have psychiatric conditions, including major depression and post-traumatic stress disorder, have shown corticolimbic dysregulation (Schechter et al. 2011, Schechter & Willheim 2009) and enlarged amygdala volume (Lupien et al. 2011). The longer-term outcomes for children are also well documented. Children of postnatally anxious mothers are more likely to show internalising difficulties (Barker et al. 2011). Children of depressed mothers are more likely to experience deficits in cognitive and language development, behavioural and emotional disturbances, attachment insecurity and social incompetence (Grace et al.

2003, Murray & Cooper 1996, Teti et al. 1995). Depression severity and chronicity have been identified as the major factors mediating the relationship between postnatal depression and child outcomes (Brennan et al. 2000, Cornish et al. 2005, Grace et al. 2003, McMahon et al. 2006), but maternal self-efficacy, depression recurrence over the first four and a half years of a child’s life, and maternal ‘state-ofmind’ regarding attachment are also relevant (McMahon et al. 2006, Philipps & O’Hara 1991, Teti 1991).

Care and Treatment Given the widespread negative impacts of maternal depression and anxiety, the importance of early identification and intervention is clear. In New South Wales, the ‘Safe Start’ policy has led to the integration of mandatory universal screening for depression, anxiety and psychosocial risks into routine perinatal care (NSW Department of Health 2009). Within this model, women identified to be suffering or at risk of developing perinatal mental illness are offered support and treatment. Sometimes this involves low-level contact from a health professional or attendance at a support group. At other times, it means psychotropic medication or a referral for psychotherapy.

In the postnatal period, assistance with sleep, settling or breastfeeding issues, or therapeutic interventions targeting postnatal depression and anxiety, parenting sensitivity and the parent-child relationship are also common.

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for the delivery approached, a written Care Plan was drawn-up in consultation with the couple and copies were sent to the relevant maternity unit staff, who were also pleased to have clear information about her struggles, likely needs and possible remedies. For example, Jessica was very disappointed that she had never succeeded in breast-feeding Andy and wanted to try again this time.

The delivery was complicated, but the baby girl arrived safely. Jessica reported with surprise and delight how helpful all the staff had been. As Jessica had known the baby’s gender Needless to say, attempts to ensure such comprehensive care for perinatal women and their families have not been without challenge (Barnett 2011). Collaboration among disciplines is essential, but such integration often evokes resistance—for example, over ‘contested boundaries’. Expecting professionals to work in a different way, without providing appropriate training, support and back-up resources, such as specialised mental health services, is not enough to implement change. Concerns have been raised about resource implications resulting from these strategies, but in reality, few women in whom risk factors are identified require specialised secondary or tertiary level intervention, and many interventions, occurring at primary and community levels merely require those involved to think and work differently.

Some disputation exists concerning the use of screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al. 1987); however, as with many aspects of psychiatry (cf. the use of psychotropic medications in pregnancy or any other life stage with the use of non-psychiatric medications and treatments) the controversy is not based on evidence but rather on stigma and personal attitudes to matters psychiatric. The beyondblue/ NHMRC Clinical Practice Guidelines for Depression and Related Disorders discuss these various issues and set out possible pathways to care (Austin et al. 2011).

Conclusion The perinatal period 1) requires considerable adjustment on the part of both parents, 2) results for some in temporary or even permanent deterioration in mental health, and 3) is critical for the growth and development of the foetus/infant and the future wellbeing of all family members (Royal Australian College of Obstetricians and Gynaecologists 2012). In the past two decades, given the known prevalence and impacts of perinatal depression and anxiety, emphasis has been placed on programs seizing the opportunity offered by pre-conception, antenatal and early postpartum health care to recognise illness, precursors and antecedents and to intervene, preferably before foetal harm occurs and the compromised infant arrives.

References Alder, J, Fink, N and Bitzer, J 2007, ‘Depression and Anxiety in Pregnancy: A Risk Factor for Obstetric, Fetal and Neonatal Outcomes? A Critical Review of the Literature’, Journal of Maternal-Fetal and Neonatal Medicine, 20: 189-209 Austin, M-P, Hadzi-Pavlovic, D, Leader, L, Saint, K and Parker, G 2005, ‘Maternal Trait Anxiety, Depression and Life Event Stress in Pregnancy: Relationships with Infant Temperament’, Early Human Development, 81: 183-190 Austin, M-P, Hadzi-Pavlovic, D, Priest, SR, Reilly, N, Wilhelm, K, Saint, K and Parker, G 2010, ‘Depressive and Anxiety Disorders in the Postpartum Period: How Prevalent Are They and Can We Improve Their Detection?’, Archives of Women’s Mental Health, 13: 395-401 Austin, M-P, Highet N and the Guidelines Expert Advisory Committee 2011, Clinical Practice Guidelines for Depression and Related Disorders—Anxiety, Bipolar Disorder and Puerperal Psychosis—in the Perinatal Period: A Guideline for Primary Care Health Professionals, Melbourne: beyondblue and The National Depression Initiative

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prenatally, the nuances of mother-daughter relationships in this family were touched upon in therapy sessions before the birth and further work was done subsequently. Jessica continued in her therapy and on her medication for a further year, attending less frequently as she returned to work part-time when the baby was weaned at eight months. Another clinician in the treating team undertook six sessions of parent-infant work with Jessica. Jessica spontaneously made contact with her mother and invited her to the baby’s first birthday celebration. Meanwhile, Andy’s school attendance improved markedly.

Barker, ED, Jaffee, SR, Uher, R and Maughan, B 2011, ‘The Contribution of Prenatal and Postnatal Maternal Anxiety and Depression to Child Maladjustment’, Depression and Anxiety, 28: 696-702 Barnett, BEW 2011, ‘An Integrated Model of Perinatal Care’, European Psychiatric Review, 4(2): 71-74 Bergman, K, Sarkar, P, Glover, V and O’Connor, TG 2008, ‘Quality of Child-Parent Attachment Moderates the Impact of Antenatal Stress on Child Fearfulness’, Journal of Child Psychology and Psychiatry, 49(10): 1089-1098 Bergman, K, Sarkar, P, Glover, V and O’Connor, TG 2010, ‘Maternal Prenatal Cortisol and Infant Cognitive Development: Moderation by Infant-Mother Attachment’, Biol.

Psychiatry, 67: 1026-1032 Brennan, PA, Hammen, C, Anderson, MJ, Bor, W, Namjan, JM and Williams, GM 2000, ‘Chronicity, Severity, and Timing of Maternal Depressive Symptoms: Relationships with Child Outcomes at Age 5’, Developmental Psychology, 36(6): 759-766 Cooper, PJ and Murray, L 1995, ‘Course and Recurrence of Postnatal Depression: Evidence for the Specificity of the Diagnostic Concept’, British Journal of Psychiatry, 166(2): 191195 Cooper, PJ and Murray, L 1998, ‘Fortnightly Review: Postnatal Depression’, British Medical Journal, 316: 1884-1886 Cornish, AM, McMahon, CA, Ungerer, JA, Barnett, B, Kowalenko, N and Tennant, C 2005, ‘Postnatal Depression and Infant Cognitive and Motor Development in the Second Postnatal Year: The Impact of Depression Chronicity and Infant Gender’, Infant Behavior and Development, 28: 407-417 Cox, J and Barton, J 2010, ‘Maternal Postnatal Mental Disorder: How Does it Affect the Young Child?’ in S Tyano, M Keren, H Herrman and J Cox (Eds) Parenthood and Mental Health, London: Wiley-Blackwell Cox, JL, Holden, JM and Sagovsky, R 1987, ‘Detection of Postnatal Depression: Development of the 10-Item Edinburgh Postnatal Depression Scale’, British Journal of Psychiatry, 150: 782-786 Crockenberg, SC and Leerkes, EM 1993, ‘Infant Social and Emotional Development in Family Context’ in CH Zeanah (Ed.) Handbook of Infant Mental Health, New York: The Guilford Press, 60-90 Fisher, J, Mello, CD, Patel, V, Rahman, A, Tran, T, Holton, S and Holmes, W 2012, ‘Prevalence and Determinants of Common Perinatal Mental Disorders in Women in Low- and Lower-Middle-Income Countries: A Systematic Review’, Bulletin of the World Health Organization, 90: 139-149 Fox, NA and Hane, AA 2008, ‘Studying the Biology of Human Attachment’ in J Cassidy and PR Shaver (Eds) Handbook of Attachment: Theory, Research, and Clinical Applications, New York: The Guilford Press, 217-240 Gavin, AR, Gaynes, BN, Lohr, KN, Meltzer-Brody, S, Gartlehner, G and Swinson, T 2005, ‘Perinatal Depression: A Systematic Review of Prevalence and Incidence’, Obstetrics and Gynecology, 106: 1071-1083 Grace, SL, Evindar, A and Stewart, DE 2003, ‘The Effect of Postpartum Depression on Child Cognitive Development and Behavior: A Review and Critical Analysis of the Literature’, Archives of Women’s Mental Health, 6: 263-274 Grant, K-A, McMahon, C, Reilly, N and Austin, M-P 2010, ‘Maternal Sensitivity Moderates the Impact of Prenatal Anxiety Disorder on Infant Mental Development’, Early Human Development, 86: 551-556 Laplante, DP, Barr, RG, Brunet, A, Du Fort, GG, Meaney, ML, Saucier, J-F, Zelazo, PR and King, S 2004, ‘Stress During Pregnancy Affects General Intellectual and Language Functioning in Human Toddlers’, Pediatric Research, 56(3): 400-410 Lewis, G 2007, ‘Saving Mothers Lives: The Seventh Report on Confidential Enquiries into Maternal and Child Health’, London: CEMACH Lupien, SJ, Parent, S, Evans, AC, Tremblay, RE, Zelazoi, PD, Corboj, V, Pruessner, JC and Séguin, JR 2011, ‘Larger Amygdala But No Change in Hippocampal Volume in 10-YearOld Children Exposed to Maternal Depressive Symptomatology Since Birth’, Proceeds of the National Academy of Science USA, 108: 14324-14329 McMahon, C, Barnett, B, Kowalenko, NM and Tennant, CC 2006, ‘Maternal Attachment State of Mind Moderates the Impact of Postnatal Depression on Infant Attachment’, Journal of Child Psychology and Psychiatry, 47(7): 660-669 Moore, PS, Whaley, SE and Sigman, M 2004, ‘Interactions Between Mothers and Children: Impacts of Maternal and Child Anxiety’, Journal of Abnormal Psychology, 113(3): 471-476 Murray, L and Cooper, PJ 1996, ‘The Impact of Postpartum Depresion on Child Development’, International Review of Psychiatry, 8: 55-63 NSW Department of Health 2009, NSW Health/Families NSW Supporting Families Early Package—SAFE START Strategic Policy, North Sydney: NSW Department of Health O’Connor, T, Heron, J, Glover, V and The ALSPAC Study Team 2002, ‘Antenatal Anxiety Predicts Child Behavioral / Emotional Problems Independently of Postnatal Depression’, Journal of the American Academy of Child and Adolescent Psychiatry, 41(2): 2

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O’Connor, TG, Heron, J, Golding, J, Glover, V and The ALSPAC Study Team 2003, ‘Maternal Antenatal Anxiety and Behavioural / Emotional Problems in Children: A Test of a Programming Hypothesis’, Journal of Child Psychology and Psychiatry, 44(7): 1025-1036 Paulson, JF and Bazemore, SD 2010, ‘Prenatal and Postpartum Depression in Fathers and Its Association with Maternal Depression: A Meta-Analysis’, JAMA, 303: 1961-1969 Philipps, LHC and O’Hara, MW 1991, ‘Prospective Study of Postpartum Depression: 4 ½ Year Follow-Up of Women and Children’, Journal of Abnormal Psychology, 100(2): 151-155 Phillips, J, Sharpe, L and Matthey, S 2007, ‘Rates of Depressive and Anxiety Disorders in a Residential Mother-Infant Unit for Unsettled Infants’, Australian and New Zealand Journal of Psychiatry, 41: 836-842 Phillips, J, Sharpe, L, Matthey, S and Charles, M 2009, ‘Maternally Focused Worry’, Archives of Women’s Mental Health, 12: 409-418 Ross, LE and McLean, LM 2006, ‘Anxiety Disorders During Pregnancy and the Postpartum Period: A Systematic Review’, Journal of Clinical Psychiatry, 67(8): 1285-1298 Royal Australian College of Obstetricians and Gynaecologists 2012, Perinatal Anxiety and Depression (C-Gen 18) viewed 30/10/2012 at http://www.ranzcog.edu.au/ the-ranzcog/policies-and-guidelines/college-statements/269-college-statements-andguidelines/new-statements-guidelines.html Schechter, DS and Willheim, E 2009, ‘Disturbances of Attachment and Parental Psychopathology in Early Childhood’, Child and Adolescent Psychiatric Clinics of North America, 18: 6665-6686 Schechter, DS, Moser, DA, Wang, Z, Marsh, R, Hao, XJ, Duan,Y, Yu, S, Gunter, B, Murphy, D, McCaw, J, Kangarlu, A, Willheim, E, Myers, MM, Hofer, MA and Peterson, BS 2011, ‘An fMRI Study of the Brain Responses of Traumatized Mothers to Viewing their Toddlers During Separation and Play’, Social Cognitive and Affective Neuroscience, viewed 30/10/2012 at http://scan.oxfordjournals.org/ content/early/2011/10/22/scan.nsr069.full.pdf Seifer, R and Dickstein, S 1993, ‘Parental Mental Illness and Infant Development’ in CH Zeanah (Ed.) Handbook of Infant Mental Health, New York: The Guilford Press, 145-160 Steele, H and Steele, M (Eds) 2008, Clinical Applications of the Adult Attachment Interview, New York: Guilford Press Stuart, S, Couser, G, Schilder, K, O’Hara, MW and Gorman, L 1998, ‘Postpartum Anxiety and Depression: Onset and Comorbidity in a Community Sample’, Journal of Nervous and Mental Disease, 186(7): 420-424 Teti, DM Gelfand, DM 1991, ‘Behavioral Competence Among Mothers of Infants in the First Year: The Mediational Role of Maternal Self-Efficacy’, Child Development, 62: 918-929 Teti, DM and Gelfand, DM, Messinger, DS and Isabella, R 1995, ‘Maternal Depression and the Quality of Early Attachment: An Examination of Infants, Preschoolers, and Their Mothers’, Developmental Psychology, 31(3): 364-376 Van den Bergh, BRH and Marcoen, A 2004, ‘High Antenatal Maternal Anxiety is Related to ADHD Symptoms, Externalizing Problems, and Anxiety in 8- and 9-Year Olds’, Child Development, 75(4): 1085-1097 Van den Bergh, BRH, Mennes, M, Oosterlaan, J, Stevens, V, Stiers, P, Marcoen, A and Lagae, L 2005, ‘High Antenatal Maternal Anxiety is Related to Impulsivity During Performance on Cognitive Tasks in 14- and 15-Year-Olds’, Neuroscience Biobehavioral Reviews, 29: 259-269 Weinstock, M 2008, ‘The Long-Term Behavioural Consequences of Prenatal Stress’, Neuroscience and Biobehavioral Reviews, 32: 1073-1086 Wenzel, A, Haugen, EN, Jackson, LC and Robinson, K 2005, ‘Anxiety Symptoms and Disorders at Eight Weeks Postpartum’, Journal of Anxiety Disorders, 19: 295-311

Suggested Reading Cox, J and Barton, J 2010, ‘Maternal Postnatal Mental Disorder: How Does It Affect the Young Child?’, S Tyano, M Keren, H Herrman, and J Cox (Eds) in Parenthood and Mental Health: A Bridge Between Infant and Adult Psychiatry, London: WileyBlackwell, 217-227 Henshaw, C, Cox, J and Nicholls, K 2009, Modern Management of Perinatal Psychiatric Disorders, London: Royal College of Psychiatrists Martin, CR (Ed.) 2012, Perinatal Mental Health: A Clinical Guide, Keswick, UK: M&K Update Ltd. Sved Williams, A and Cowling, V (Eds) 2008, Infants of Parents with Mental Illness, Developmental, Clinical, Cultural and Personal Perspectives, Bowen Hills, Queensland: Australian Academic Press

Jane Kohlhoff, PhD, is a practicing clinical psychologist and the Research Coordinator at Karitane, an early parenting organisation in Carramar, NSW. She has a conjoint lecturer position at the UNSW. Her research interests include perinatal psychology, infant mental health, attachment theory, parenting, and interventions for early childhood behavioural disorders. Jane has published a number of peer-reviewed journal articles and has presented at many national and international conferences.

Bryanne Barnett, AM, is a perinatal and infant psychiatrist who works at Karitane and St John of God Healthcare. She holds a conjoint professorship at the UNSW. Bryanne has a particular interest in early intervention, prevention and health promotion, and has initiated many research and clinical programs with those goals in mind, including the Integrated Perinatal Care (IPC-SAFE START) program in public hospital maternity units, Jade House and the Toddler Clinic at Karitane, and the Raphael Centre at Blacktown with St John of God Health Care. She has also worked extensively with beyondblue, the National Depression Initiative.

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Features

Positive Mental Health:Contributions In 1958, in a provocative book for its time, Current Concepts of Positive Mental Health, Marie Jahoda argued for understanding psychological wellbeing in its own right, not merely as the absence of disorder or distress. Other contemporaries at the time—primarily in the field of Humanistic Psychology, such as Abraham Maslow and Carl Rogers—also argued for a ‘positive psychology’. Despite these early calls to consider ‘positive mental health’, psychology has, generally speaking, been focussed primarily on ‘negatives’ and ‘deficits’. With the rise of Positive Psychology, a paradigm shift is occurring.

The Emergence of Positive Psychology Positive Psychology was officially launched in the US in 1998 when Martin Seligman gave his first address as President of the American Psychological Association. Positive Psychology has been defined as the scientific study of the conditions and processes that contribute to the flourishing or optimal functioning of people, groups and institutions (Gable & Haidt 2005). Its underlying premise is that mental health is more than the absence of mental illness, and that it is valid and important to enhance wellbeing and cultivate positive emotions (Keyes 2007).

Noble and McGrath (2008) claim that many of the components of Positive Psychology are not new, and Linley and Joseph (2004) believe that it is a useful umbrella term that has the potential to unite a range of related but disparate directions in theory and research about what makes life worth living. Positive Psychology can be differentiated from previous ‘positive’ approaches in psychology, such as Humanistic Psychology, by the fact that it is firmly grounded in empirical research (Seligman 2007).

Creating Positive Mental Health The twentieth century focus on treatment of mental health disorders saw the rise of many successful pharmacological and psychological treatments. Positive Psychology and its related study of wellbeing provide a firm scientific foundation to underpin mental health promotion in the service of the century of positive mental health. A key focus of Positive Psychology is the investigation of wellbeing and resilience and on creating evidence-based positive interventions for individuals, groups, communities and organisations aimed at creating positive mental health and wellbeing, not on only reducing symptoms of mental illness. It appears that mental health in the twentyfirst century may move towards mental health promotion and positive interventions that may complement the science of mental illness prevention and treatment (Keyes & Lopez 2002). Evidence for this move towards a more proactive and positive approach can also be evidenced by the growing ‘Positive Education’ movement (Seligman 2009), which was formally launched by Geelong Grammar School’s engagement of Seligman and the University of Pennsylvania’s initiative to create a whole school ‘Positive Education Program’ aimed at 26

increasing wellbeing as well as reducing depression. Since that time, other Australian schools including Knox Grammar School in Sydney, Tully State High School in Queensland and St Peter’s College in Adelaide have also commenced large-scale Positive Education Programs. In addition, Seligman and colleagues have been engaged by the United States Army to design and deliver a Comprehensive Soldier Fitness (CSF) Program based on the principles of Positive Psychology and aimed at increasing psychological strengths and positive performance and to reduce the incidence of maladaptive responses of the entire Army. It has been suggested that this program may provide a model for implementing similar interventions in other very large institutions (Cornum et al. 2011).

Wellbeing A core component of ‘positive mental health’ is wellbeing.

The study of wellbeing is, however, complex and currently controversial, with reference often being made to subjective wellbeing (SWB) and psychological wellbeing (PWB).

SWB consists of life satisfaction and a positive ratio of positive to negative affective states. The terms SWB and happiness are often used interchangeably. Ryff and Keyes (1995) refer to psychological wellbeing (PWB) as being distinct from SWB. They developed a multidimensional approach to the measurement of PWB that defines six different aspects of human actualisation: autonomy, personal growth, self-acceptance, life purpose, mastery and positive relatedness.

A separate but related approach when considering wellbeing is that of psychological needs. Self-Determination Theory (Deci & Ryan1985) postulates three psychological needs imperative to our wellbeing: competence, autonomy and relatedness. More recently, Seligman (2011) has articulated wellbeing theory as comprising positive emotions, engagement, relationships, meaning and accomplishment, or PERMA (for a full description of PERMA refer to Seligman 2011).

WellBeing Therapy (WBT), a specific psychotherapy for enhancing wellbeing has been developed (Fava 1999b) and tested in controlled trials for patients with affective disorders, both alone (e.g., Fava et al. 1998a) and in addition to CBT (e.g., Fava et al. 2004, Fava et al. 2005). WBT is based on Carol Ryff’s (1989) six dimensions of psychological wellbeing: autonomy, environmental mastery, personal growth, purpose in life, positive relations, and self acceptance. Interventions that target the positive may address an aspect of functioning and health that is typically left unaddressed in conventional treatments.

Such interventions are crucial in clinical populations at high risk for relapse, such as major depression.

Positive Interventions In the past fourteen years, there has been increasing interest in understanding not only ways to prevent mental illness but also ways to promote mental wellbeing, through what are known as ‘Positive Psychology Interventions’ (PPIs). One of the earliest ‘positive CQ: The CAPA Quarterly

from the Science of Positive Psychology interventions’ identified was created by Fordyce (1977), who created and tested a ‘happiness intervention’ consisting of fourteen strategies, such as increasing activity, increasing socialisation, engaging in meaningful work, forming close relationships, lowering expectations and prioritising happiness. His study found students in the ‘intervention’ condition were happier, less anxious and less depressed at the end of the term than participants in the control groups. Duckworth, Steen and Seligman (2005) claim Fordyce’s scientific research was substantial, because he demonstrated the possibility of making people happier.

Since the inception of Positive Psychology, increasing scientific research supports the efficacy and effectiveness of PPIs. PPIs are intentional activities that aim to increase wellbeing through the cultivation of positive feelings, cognitions and behaviours.

Examples of PPI’s include: identifying and developing strengths, cultivating gratitude, and visualising best possible selves (Seligman et al. 2005, Sheldon & Lyubomirsky 2006). A metaanalysis conducted by Sin and Lyubomirksy (2009) of fifty-one PPIs with 4,266 individuals revealed that PPIs do significantly increase wellbeing and decrease depressive symptoms.

PPIs may also have a particular benefit for those suffering depressive disorders. Whilst at this time the majority of positive interventions have been conducted with non-depressed individuals, some initial studies have reported promising initial findings (Layous et al. 2011). As such, positive interventions may also be offered as ‘depression-proofing’ for those who may be sub-clinically depressed or be at risk of relapse. For example, Seligman et al. (2006) created a form of ‘Positive Psychotherapy’ (PPT) which focuses on identifying and promoting the use of strengths and individually meaningful activities, savouring positive experience, and gratitude. A number of validation studies of PPT have been completed. Individual PPT with severely depressed clients led to more symptomatic improvement and to more remission from depressive disorder than treatment-as-usual and than treatment-as-usual plus antidepressant medication. PPT also measurably enhanced happiness (Seligman et al. 2006).

For those who may be in the moderately mentally healthy range, with a desire to flourish (Keyes 2007), evidence-based coaching may be an option. There have been recent calls for the integration of Positive Psychology and evidence-based coaching (Green & Spence 2012). Evidence-based coaching, with its lack of stigma, may also be considered a PPI with its primary aim of increasing goal attainment and wellbeing. Grant and Spence (2010) have argued that the context provided in coaching is valuable, because it permits the presentation of “user-friendly applications of positive psychological knowledge” (p. 177) to individuals who might find them beneficial across multiple domains of life and/or who might not otherwise have exposure to them.

Many health professionals are beginning to realise the benefits of incorporating positive interventions like “positive psychology

Suzy Green

coaching” into their practices (see Biswas-Diener 2010). Thus, coaching may be used to destigmatise psychology and promote its applicability to a wider population in the spirit of giving psychology away (Miller 1969).

Positive interventions, including evidence-based life coaching, may also be used for those individuals who in the past presented with ‘problems in living’ or, as Egan (1998) refers to, as “unused opportunities”. These clients are individuals without a DSM-IV diagnosis and who are not typically ‘dogged’ by problems but are not as effective as they would prefer to be.

Relevance for the Mental Health Professional There is an enormous thirst and increasing interest in the concept of happiness and wellbeing in the wider community. This is highlighted by popular magazine articles on happiness e.g., ‘how to be happy’. Given the significant amounts of ‘popular psychology’ being made available to the public, particularly in regard to ‘happiness’, it is essential that mental health professionals stay informed of current scientific research on and best practice in the promotion of wellbeing in order to educate and inform our communities. Mental health professionals also need to be aware of the potential dangers that superficial applications of ‘thinking positively’ can have with the potential consequence of a negative outcome, particularly for vulnerable individuals who may be clinically depressed or suicidal.

Implications for Practice For mental health professionals, the growing research base of Positive Psychology and associated PPIs, including evidencebased coaching, could have significant implications for practice.

For example, an evidence-based life-coaching program for clients assessed as non-clinical could be used in order to design a future that creates wellbeing and diminished mental illness.

Other positive interventions suitable for individuals might include practicing gratitude, acts of kindness, identifying and using strengths.

Whilst there is increasing scientific support for PPIs, it should be noted many PPIs are aimed at a ‘normal population’ rather than a ‘clinical population’, and research on the use of PPIs in clinical settings is embryonic. There are concerns that without a thorough psychological assessment prior to conducting the intervention, there may be a real danger of a negative outcome, rather than the intended positive one. For example, if school students were to undertake a coaching intervention and fail to achieve their goals due to an underlying clinical disorder such as depression, there may be a danger of worsening the clinical disorder, rather than improving the child’s wellbeing.

Conclusion A growing evidence base suggests that using PPIs can increase wellbeing. Such programs, with their lack of stigma, may assist in increasing wellbeing and potentially achieve savings in mental health costs. (continued on Page 34)

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Modality Profile

Neurofeedback

Neurofeedback, or neurobiofeedback as it is sometimes known, uses displays of functional magnetic resonance imaging (fMRI) to illustrate brain activity, including the activity of both the right and left hemispheres. Certain electrical activity correlates to specific operations of the brain that is indicative of, for example, sleep, wakefulness, and trauma responses, such as dissociation and hyper-arousal, emotional reactivity, anxiety, relaxation, focussed attention and problem solving. Neurofeedback has been used as an adjunct to many therapies. STARTTS [the NSW Service for the Treatment and Rehabilitation of Trauma and Torture Survivors] has a neurofeedback centre, which is used in conjunction with trauma treatment models. Some cognitive behavioural therapists use neurofeedback to increase a person’s capacity to take on more helpful cognitions and move into less anxious states. It has been widely used to reduce the effects of Attention Deficit Hyperactivity Disorder (ADHD), particularly impulsivity, hyperactivity and concentration (Bakhshayesh et al. 2011) as well as providing a reduction in obsessivecompulsive behaviour (Sürmeli & Ertem 2011). Whilst there is still much more research to be conducted into neurofeedback compared to other interventions, there are now over 1500 peerreviewed papers supporting its effectiveness, including research that claims neurofeedback is more tolerated by war veterans than conventional desensitisation and exposure techniques (Othmer & Othmer 2009). In regard to depression, a study conducted in 2011 concluded that neurofeedback significantly facilitated the amelioration of symptoms and increased learning compared to a CBT-alone intervention (Linden 2012).

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At the Family Systems Institute in Sydney, neurofeedback is used specifically to facilitate people’s ability to respond more thoughtfully to situations in which they may otherwise react automatically as they adapt to life and relationship challenges.

There are many different types of neurofeedback systems.

Most focus on ‘tweaking’ certain areas of the brain, that is, controlling central nervous system (CNS) activity based on comparisons with a database of ‘normal’ brain activity and how a brain ‘should’ perform. This overt focus on a particular area of the brain’s functioning is called ‘up-training’, and involves the operator targeting certain areas of the brain for intervention. An example of this is when beta brain waves—the ‘busy’ waves (~13 Hz) that are produced when a person is awake and alert with eyes open—are up-trained in order to improve problems in focus and attention. The downside is that while individuals may lack focus in order to mediate the level of anxiety they experience, and up-training can improve their concentration, it also increases their anxiety (Zengar Institute). According to John Thompson, a Perth-based neurofeedback trainer and supervisor, who used neurofeedback successfully with Bali bombing survivors, the brain is too complex a system for us to even begin to think we know what it should do, or to predict how it may ‘compensate’ for an external manipulation of an adaptation that may have at one time been useful to us, even if that is no longer the case.

Thompson writes, “With up to 100 billion neurons (brain cells), with each neuron having as many as 30,000 connections … one estimation is that in 2007 the world’s total combined CPU computing power was equal to one human brain. Even with the

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brain being that dynamic and complex, we do not understand many of the guidelines it operates by” (Thompson 2012).

NeurOptimal® neurofeedback is a specific and unique system, according to its Canadian inventor Dr Val Browne from the Zengar Institute, that allows the brain to train itself—no ‘tweaking’ required—to ‘decide’ how and what to adjust in terms of the patterns of its brain waves in order to work more efficiently and improve functioning. When a specific type of turbulence is detected that indicates that the CNS is unable to process seamlessly information that allows for a smoother transition from one emotional state to another (such as moving from an anxious to a non-anxious state when any external stimulus for the anxiety is removed), an ‘interruption’ occurs in the audio or visual display, which is then fed back to the brain almost immediately. An interruption is clearly heard via a break or ‘crackling’ in the music the client listens to and, likewise, there is a break in the visual imagery that the client can watch on the monitor. Think of an elastic band on one’s wrist used to remind oneself of something or to interrupt a habit, like biting one’s nails. The brain similarly recognises the interruption and tries to correct itself by facilitating optimal functioning. Over time, out-dated, less preferable neural pathways cease taking the ‘heavy traffic’ of our functioning, and new neural pathways develop to promote a more efficient, optimised state of health and wellbeing.

Clients who have used neurofeedback report many positive changes, including feeling calmer, more capable of focussed action with less procrastination, feeling less sensitive to others’

February 2013

expectations, and even experiencing complete cessation of migraine headaches—the effects of which are similar to exercise in terms of the level of emotional and psychological wellbeing experienced.

Unlike exercise, which must be maintained for ongoing physical health, neurofeedback does not have to be undertaken indefinitely.

Once new neural pathways have been created, which is evidenced by the ease in which individuals can maintain optimimal performance across more areas of their processing, they do not have to keep using neurofeedback. More and more athletes, dancers and musicians are using neurofeedback to enhance their creativity and performance, achieving outstanding results.

References Bakhshayesh, A, Hänsch S, Wyschkon, A, Rezai, M and Esser G 2011, ‘Neurofeedback in ADHD: A Single-Blind Randomized Controlled Trial’, European Child & Adolescent Psychiatry, 20(9): 481-91 The Family Systems Institute, http://www.familysystemstraining.com/systems-and-the-brain/ Linden, DEJ, Habes, I, Johnston, SJ, Linden, S, Tatineni, R, Subramanian, L, Sorger, B, Healy, D and Goegel, R 2012, ‘Real-Time Self-Regulation of Emotion Networks in Patients with Depression (Neurofeedback in Depression)’, PLoS ONE, 7(6):e38115 viewed on 25/11/12 at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.

0038115;jsessionid=C41071AC8F770E6F14010986AAD668AC Neurotribe: Neurofeedback Training Resources, http://www.neurotribe.com NSW Service for the Treatment and Rehabilitation of Trauma and Torture Survivors (STARTTS), http://www.startts.org.au/default.aspx?id=278 Othmer, S and Othmer, Susan F 2009, ‘Post Traumatic Stress Disorder—The Neurofeedback Remedy’, Journal of Biofeedback, 37(1): 24-31 Sürmeli, T and Ertem, A 2011, ‘Obsessive Compulsive Disorder and the Efficacy of qEEG-Guided Neurofeedback Treatment: A Case Series’, Clinical EEG and Neuroscience, 42(3): 195-201 Thompson, J 2012, viewed on 24/11/2012 at http://www.neurotribe.com/ neurofeedback-explained Zengar Institute 2009, ‘Cartography of Consciousness’, http://zengar.com/Cartography

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In the Therapy Room

Tick-Tock, Watch the Clock The following is a collection of thoughts about time. It is not linear or conclusive. I hope it provokes thought and perhaps some discussion.

I need to declare that I’m a product of the very system that I critique here, and that most of my clinical decisions and practices are quite traditional, working within the very norms I question. I am glad I question them, wrestle them down and argue the point with them. The exercise is good for me and, I hope, for my work with clients.

I would like to beg you dear Sir, as well as I can, to have patience with everything unresolved in your heart and try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer. ~Rainer Maria Rilke Time in the Therapy Room Timing is everything, someone once said.

That feels true in the counselling room, in our profession, and in my life. Certainly, time is often a topic of conversation between modern people. But what is (the) time? How can we use our time more profitably? How can we move away from being ‘time poor’ ‘stealing some time’ for ourselves, or even ‘wasting time’?

These idioms suggest that time has become a commodity.

The psychotherapeutic practitioner’s concept of time is shaped by many historical influences, and understanding a little more about the way we think about time may help us to look at our work in new ways or refresh our practice ‘in the nick of time’. The context in which we live shapes us, our thinking and the way we work; taken-for-granted ways of seeing can blind us to new possibilities.

Prior to the Industrial Revolution our modern view of ‘losing time’, ‘making some time’ or ‘finding some time’ probably did not exist. Time pieces evolved largely because workers’ time became a commodity. No longer were workers paid for a job or task; they were paid for the amount of time they worked and for being ‘on time’. This is a very recent change, yet it can be hard for us to imagine a world without clocks and harder still to imagine our work without the tight, modern concept of time where ‘time is money’.

The Therapy Hour: How Long is a Session?

Thanks to Freud, Jung and others, we have a rich legacy that has shaped our presuppositions about time and therapy.

So we have the term, ‘the therapy hour’, which is often fifty 30

minutes, and the notion that clients should attend sessions at regularly spaced intervals. These ideas have become so central to our concepts of therapy that many identify these norms as rules or foundational tenets. We are expected, on the whole, to ‘hold the boundary’ of the strictly timelimited therapy session and to observe these and other time conventions as if they are Truth.

Of course, I acknowledge that there are schools of thought that tweak the edges of these ways of doing therapy, yet the core of much of what we do is bounded by a taken-for-granted way of ‘doing’ time. What would happen if we were to be open to different ways of seeing, knowing and doing time? How might that shape the way we work? Would it transform cross-cultural counselling? Counselling of children? The aged? Would it change us?

Let’s take the notion of a set time for a session. Fifty or sixty minutes of our time is exchanged for a sum of money or stats contributed to an agency or boss—all leading ultimately to a pay cheque. I heard it said of a colleague, “He has poor boundaries”, because the counsellor chose to go over-time— the sacred hour—with a few of his clients. In an agency setting, I once needed to present some pretty strong arguments and attend extra supervision when I believed a client needed longer sessions for a period of time. The exception was granted, but the point was made that such a deviation from the norm would be treated with care or even suspicion. I respect the needs of agencies to be fully accountable and to keep good statistics for their hard-earned funding, but that is not my point.

When did we decide that sixty minutes has a magical quality capable of being the measure of one’s professionalism, ethics and boundaries? ‘Look at the time!’ That is what our profession often says. What would happen if this changed to ‘Do it in your own time’ or even ‘Give it time’? Chaos may ensue! ‘Time will tell’ …

Quality Time: How Many Sessions?

The term ‘brief therapy’ is framed around this modern notion of time. It is interesting that time itself, i.e., a short amount of time, can define a type of therapy. The time limits here are not concerned with the length of each session. Rather, it is the number of sessions that becomes the focus. The focus is on achieving more with less time—and money—because ‘time is money’.

These questions do not judge the value of time-limited versus long-term psychotherapy. Personally, I use a range of approaches according to clients’ context, needs and resources.

Some clients need to make a decision; others are dealing with complex trauma or entrenched multi-dimensional problems.

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Jewel Jones

I am pointing out that we should not automatically accept particular cultural framings of issues in terms of time limits.

Clients’ goals and needs, rather than time frameworks need to be our focus.

Again, there is the temptation to put a value on the time framework we choose: ‘Short term is best, and anyone who does long-term work with clients is doing it for their ego, the money, or because they are co-dependent.’ Alternatively, those who do brief therapy ‘are in their heads or have not done their own personal work’. Time is turned into the arbiter of good practice … Time becomes the ‘Time Lord’.

Perhaps we need to put time in its place. After all, it is a socially constructed notion at best, and we could be at risk of becoming servants to a time-limited concept, an idea. I accept that we have traditions and norms, but let us not elevate them to Laws. Time may heal all wounds in folklore or not, as John Farnham sings: “Time has a way of wounding what is healed …”. Perhaps he has a point, when we time-limit clients who need more session time or more sessions.

Get the Timing Right: Time in the Session Perhaps you see clients for two sessions only. Maybe you are into long-term work. Your sessions could take two and a half hours or twenty minutes.

Picture yourself in a counselling session: you and the client(s), perhaps a big bag of wool (for pulling over clients’ eyes?), a kit bag of skills, and a couple of frames or models dusted off in the corner. The clock is ticking.

What happens to time when you are counselling? How do you use it, serve it, ignore it or take charge? Some of us are clock watchers, especially if the session is dragging or we are feeling sleepy with a client. It’s amazing how long ten minutes can be when a session is not going well. I’ve had times when the first half of a session is unbelievably slow … a shift occurs … then the end of the session arrives unbidden, causing chaos as I help the clients ‘land’, ready to face the rest of their day.

On a good day, there is a rhythm and flow to the work, and I am able to pace the session so we have adequate time at the end to review it. Silences may last a minute or two but it doesn’t feel awkward. There may be sections of fast repartee between myself and the client, and my interventions feel well timed. We both feel in sync. Sometimes I am able to explain this sense of good timing; sometimes, I cannot locate a clinical reason for the changed sense of time passing.

What are your experiences of time in a session, and what sense do you make of them? Ending a session has its own timing issues. If we are working deeply with a client, it is important to allow ten to fifteen minutes to ground the client before the end of the session. I often look at the clock to check February 2013

whether there is enough time remaining to use a particular intervention to ‘bring the client back’. Over time, it has been easier to get a sense of how much time is needed to use a particular tool, although each client is an individual, and it is an illusion to think we can control timing or any other aspect of our work.

That said, there are times when I recontract with the client to go overtime if I sense this would be in the client’s best interest.

For example: fifteen minutes before the end of a session, a client makes a significant new connection about a core issue. I then have a choice about whether to end with this new insight or move forward. I work in private practice, so I have a great deal of freedom, particularly since I allow plenty of time between client appointments. When I work for an agency, however, I clearly need to adhere to policies and procedures about session length, as they are part of my contract.

Another issue regarding time is the ‘timing’ for the client in terms of developmental issues or life circumstances. If, for example, I am counselling a twenty-three year-old survivor of childhood sexual abuse, I am mindful of the possible limitations to our work due to the client’s limited life experience and stage of emotional development. If the client is in her early forties, in a stable, loving relationship and has lots of family support, then the work is likely to go deeper and longer. In this instance, the time issue is focussed on the client’s time of life. Timing is strongly influenced by the client’s timeline.

Sometimes clients need time to digest work done in counselling sessions. We may then contract to have a break and re-connect later. Ill health of the client or the counsellor can change the timing, and thus, the type of interventions used.

Some clients can only afford counselling once a month, so financial constraints impact on issues of time too.

What becomes clear is that time is not an entity that exists in a vacuum. Timing can impact on the work, and the type of work can impact on timing. It’s a two-way street. Nevertheless, perhaps it is time to take a look at time.

It seems that timing is not always everything.

References Carroll, R 2005, ‘Rhythm, Reorientation, Reversal: Deep Reorganisation of the Self in Psychotherapy’ in J Ryan(Ed.) How Does Psychotherapy Work? London: Karnac Stern, DN 2004, The Present Moment in Psychotherapy and Everyday Life, New York: WW Norton & Co.

Jewel Jones is a counsellor with over fourteen years’ counselling experience in agencies and in private practice. She has a Masters in Adult Education and her private practice is increasingly concerned with having influence through training and supervision. www.jewel-jones.com.au, jeweljones@iprimus.com.au

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Professional Development

Exploring Ethical Practice Review by Juliana Triml

Elisabeth Shaw is an individual, couple and family therapist, supervisor and trainer in private practice in Drummoyne, NSW. She was previously a Manager and Director of Relationships Australia NSW. In recent years, she has specialised in working with professional ethics. She is a member of the PACFA and APS Ethics Committees and writes a column for Psychotherapy in Australia on ethical issues in practice entitled, ‘Sacred Cows and Sleeping Dogs’. Elisabeth is co-author with Michael Carroll of Ethical Maturity in the Helping Professions, Making Difficult Life and Work Decisions (2012).

Elisabeth Shaw gave a presentation that was so much more than simply reading a list of rules and regulations. She explored the underlying reasons why very experienced therapists can still commit the gravest errors, despite all their training and good knowledge of the rules and regulations—which are, of course, subject to interpretation. She illuminated the process of discerning a rule that applies or most appeals to an individual through examples encountered in practice.

She began by pointing to the conscious reflection on one’s own work in juxtaposition to the philosophical underpinning of ethics. For example, the morality of ethics is strongly based on Socrates’ philosophy of a ‘good life’, and explores life from the position of not knowing. Aristotle added another element to this construct—that of a ‘good person’. So now we have the ‘good life’ and the actor within it, the ‘good person’. Both of these concepts can be subject to interpretation depending on our relational frame. The most effective way of learning ethics is by being around ‘good people’ who can serve as role models. In our practice, that means having supervisors who have a strong practical and theoretical knowledge of ethics.

Elisabeth discussed the dilemma: a situation that arises when more than one seemingly acceptable solution exists.

Quite often, a dilemma is further complicated by temptation and our subsequent desire to justify a possible and preferred solution. Since ethics is expressed in practice, a final decision inevitably leads to action, or it may mean taking no action. It is sometimes tempting to do nothing when something doesn’t feel right.

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The principles and qualities that underpin ethics are: moral character, a term assigned by Aristotle that asks, ‘What kind of person should I be?’ ethical maturity, a quality that changes over time the rule of good, which in deontological thinking posits ‘the greatest good to the greatest numbers’ and critical inquiry, which promotes the question ‘What should I do and who should I be?’

Elisabeth read a story about a person dealing with a dilemma involving two conflicting values—professional duty vs duty to family—which illustrated that the choosing of one inevitably creates neglect of the other. Duty to self versus duty to others may at times be blurry, and the strength of allegiance to one action may change over time.

Why do people transgress? Usually personal benefits or emotional responses play a role—such as when feeling threatened, or when seeking vengeance and wanting to de-humanize another.

Such transgressions are likely to lead to a client complaint. Taking notes is a requirement, but some therapists have a list of reasons not to keep notes to avoid misinterpretation, to avoid subpoena or to protect the client. Taking clear notes is, however, a therapist’s best defence should the need arise. This record also allows for reflection on one’s own practice. A therapist’s notes should include answers to the questions: What was done? How was the client validated?

What suggestions were given to the client?

Ethical maturity is reflected by feeling congruent with one’s own values and having ethical self awareness. These issues could be brought into a peer discussion for reflection. In some situations, it is useful to distinguish whether an ethical issue is personal or organizational. When unsure, we should consider consultation with a colleague or supervisor. If still unsure, several of the following resources can be contacted: your professional association, professional code, supervisor, literature, St. James Ethics Centre and the Healthcare Complaint Commission.

Self care and education are also helpful resources.

Juliana Triml is the CAPA NSW PD Coordinator. If you have any suggestions regarding future professional development events, please contact her at: pd@capa.asn.au

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CAPA NSW Professional Development Events CAPA NSW members must complete twenty hours of approved professional development each year. To help members meet this requirement, CAPA is hosting PDEs on the following dates:

Tuesday 12 March 2013 7.00–9.00 pm PD hours: 2 Leon Cowen

Loading the Counselling Gun with Hypnotherapy Bullets Hypnosis proposes the use of specific language patterns but very little counselling. Clinical hypnotherapy, on the other hand, uses counselling and psychotherapy language patterns coupled with the potency of hypnosis. The outcome is more relaxed clients, taking a very active role in achieving their goals more quickly. A large claim! Come to this workshop and you will have the opportunity to have all your questions answered and to see a demonstration, provided an audience member volunteers.

This is a not to be missed workshop that will blow away the hypnosis myths and demonstrate the links between counselling, psychotherapy and clinical hypnotherapy.

Leon Cowen has been a clinical hypnotherapist for thirty-seven years and is at the forefront of clinical hypnotherapy and clinical hypnotherapy training. He is the Executive Director of the Academy of Applied Hypnosis in Lindfield. Leon is a PhD candidate with the University of Western Sydney, researching educational guidelines for clinical hypnotherapy.

Wednesday 29 May 2013 7.00–9.00 pm PD hours: 2 Kevin Keith

How Can Attachment Theory ‘Inform’ My Practice?

Attachment Theory has in recent years begun to importantly inform counselling and psychotherapy. These enhancements do not represent another modality but rather provide a framework for understanding emotional development and change with our clients. This workshop combines current theory and research with practical exercises to enhance our capacities for effective assessment, goal setting and work with our clients.

Kevin Keith is a counsellor, psychotherapist and supervisor. He is a clinical member CAPA NSW/PACFA and a lecturer in JNI’s Masters Program. He is also a PhD candidate, University of Sydney, Faculty of Science (History and Philosophy of Science Unit) with research interests in Attachment Theory.

Tuesday 20 August 2013 7.00–9.00 pm PD hours: 2 Jackie Burke

Identifying Vicarious Trauma and Managing the Inevitable Triggered by analysis of attrition rates throughout the industry, the NSW Rape Crisis Centre identified psychological injury stemming from vicarious trauma as the primary health and safety hazard for its counselling staff. A comprehensive package of management strategies was developed to effectively monitor and respond to this risk. As a result of implementing this package, no psychological injury claims have been made in the past eight years, and the Centre received the 2007 Safe Work Award for the best solution to an identified workplace issue from Workcover NSW. Jackie Burke, Clinical Director of the NSW Rape Crisis Centre, will discuss the key factors in this success and examine the implications of these results for other workplaces and industry sectors. The training is suitable for frontline and managerial staff. (A maximum of twenty-five participants is recommended.)

Learning outcomes: Understand the vicarious trauma construct.

Differentiate between vicarious trauma and burnout.

Identify predictors of vicarious trauma.

Recognise symptoms of vicarious trauma.

Understand effective strategies to manage vicarious trauma.

Jackie Burke has a background in both psychology and counselling disciplines and is a pioneer in the field of Vicarious Trauma Management. She is the co-author of A Best Practice Manual for Specialised Sexual Assault Crisis Telephone and Online Counselling.

Further 2013 Professional Development Events Saturday 19 October 2013 CAPA AGM: PD topic to be assigned Tuesday or Wednesday early in December 2013 CAPA Christmas party: PD topic to be assigned Suggestions from members for future PDEs are welcome. We are selective with the choice of presenters and invite only those who have qualifications adequate to garner PD credit for attendees. Topics are under negotiation as most presenters do not like to commit too far in advance, and there is always a risk that they may cancel, sometimes at short notice.

Bookings: (02) 9235 1500 or office@capa.asn.au Please book as soon as possible. Spaces are limited due to Occupational Health and Safety requirements.

Cost: Free for CAPA members. $30 for non-members Venue: Crows Nest Centre, 2 Ernest Place, Crows Nest, Sydney (unless otherwise stated)

If you have any suggestions for future PDEs, contact PD Coordinator, Juliana Triml, on pd@capa.asn.au. CAPA is also exploring more options for members in rural and regional areas. Please email the Regional and Rural Committee with your suggestions regional@capa.asn.au.

February 2013

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Features (continued) (continued from Page 13)

(continued from Page 27)

and son went away mad at her. One must be prepared for change-back reactions from others and from within self.

Sustained change includes practice at not reacting back, increasing the ability to remain separate and steady.

Bowen theory provides a natural systems perspective within which to understand the impact of reactivity to relationships and stresses on health and functioning. This approach to therapy does not render anyone immune to the challenges of life, but it does provide a wider lens that can be used to see the part reactions play in creating symptoms. It allows the person to better manage reactions without sacrificing health and stability, while still being a resource within the family. This approach is also valuable for medical and mental health professionals in their efforts to be resources when symptoms occur.

Whilst, the debate and research continue to provide further understanding of wellbeing, it would behoove mental health professionals to maintain a curiosity about and current knowledge of the scientific study of wellbeing and Positive Psychology more broadly in order to educate clients and provide services that fall under the umbrella of mental health promotion.

References Allman, J 1999, Evolving Brains, New York: Scientific American Amar, P, McKee, MG, Peavey, BS and Schneider, CJ 1992, in MB Sterman (Ed.) Standards and Guidelines for Biofeedback Applications in Psychophysiological Self-Regulation, Denver: A APB Publication Bowen, M 1978, Family Therapy in Clinical Practice, New York: Rowan and Littlefield — —1988 ‘The Odyssey Toward Science’ in ME Kerr and M Brown Family Evaluation, New York: Norton and Company Brown, S 2012, ‘A History of NeurOptimal: An Overview of the Development and Evolution of NeurOptimal’, viewed on 28/10/2012 at http://zengar.com/ history-of-neuroptimal Calogero, A, Gallucci, WT, Gold, PW and Chrousos, G 1988, ‘Multiple Regulatory Feedback Loops on Hypothalamic Corticotrophin Releasing Hormone Secretion’, The Journal of Clinical Investigation, 82: 767-774 Deits, F 2004, Focused Technology F1000 Instrumentation System Manual, viewed on 28/10/2012 at http://focused-technology Group for the Advancement of Psychiatry (GAP), Bowen, M and The Committee on the Family 1970, ‘The Field of Family Therapy’, Group for the Advancement of Psychiatry Report, 6(78), New York: GAP Harrison, V 1989, ‘The Regulation of Self in Relationships’, Biofeedback Frontiers, New York: AMS Press ——1999 ‘A Better Chance: A Series on Systems Therapy Based in Bowen Theory’, Family Systems Forum, 1(3-4) and 4(2-3) ——2004, ‘Understanding and Managing Emotional Reactivity in Chronic Illness’, Family Systems Forum, 6(2) ——(in press), ‘Emotional Reactivity, Fusion and Differentiation in Family Physiology: Clinical Case Research’ in P Titleman (Ed.) Differentiation of Self: Bowen Family Systems Theory Perspectives, New York: Routledge, Taylor and Francis Group Harrison, V, Rowan, K and Mathias, J 2005, ‘Stress Reactivity and Family Relationships in the Development and Treatment of Endometriosis’, Fertility and Sterility, 83: 857-864 Kerr, M 1992 ‘Physical Illness and the Family Emotional System’, Behavioral Medicine, 18(3): 106 McEwen, B 2002, The End of Stress as We Know It, New York: Dana Press Panksepp, J 1998 Affective Neuroscience: The Foundations of Human and Animal Emotions, New York: Oxford University Press Porges, S 2009, ‘The Polyvagal Theory: New Insights into Adaptive Reactions of the Autonomic Nervous System’, Cleveland Clinic Journal of Medicine, 76: 86-90 Rosenbaum, L 1989, Biofeedback Frontiers, New York: AMS Press Sapolsky, R 1994, Why Zebras Don’t Get Ulcers, New York: W.H. Freeman Zimmer, C 2005, ‘The Neurobiology of Self ’, Scientific American Mind, 293: 92-101 Victoria Harrison, MA, LMFT, is a psychotherapist and founding Director of the Center for the Study of Natural Systems and the Family (www.csnsf.org) in Houston, Texas where she also has a clinical practice. She commutes to Washington, DC where she serves on the faculty of Bowen Center for the Study of the Family (www.thebowencenter.org) and directs the postgraduate program there. Victoria teaches Bowen theory with a focus on health and reproduction throughout the world. In 2010, she taught at the Family Systems Institute in Sydney (www.thefsi. com.au) where the faculty provide educational programs and clinical services based in Bowen theory and use neurofeedback for self-regulation of reactivity.

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References

Biswas-Diener, R 2010, Practicing Positive Psychology Coaching: Assessment, Diagnosis and Intervention, New York: John Wiley & Sons Cornum, R, Matthews, MD and Seligman, MEP 2011, ‘Comprehensive Soldier Fitness’, American Psychologist, 66(1): 4-9 Deci, EL and Ryan, RM 1985, Intrinsic Motivation and Self-Determination in Human Behaviour, New York: Pienum Duckworth, AL, Steen, TA and Seligman, MEP 2005, ‘Positive Psychology in Clinical Practice’, Annual Review of Clinical Psychology, 1: 629-651 Egan, G 1998, The Skilled Helper (6th edn), Pacific Grove, CA: Books/Cole Publishing Company Fordyce, MW 1977, ‘Development of a Program to Increase Personal Happiness’, Journal of Counseling Psychology, 24: 511-520 Gable, SL and Haidt, J 2005, ‘What (and Why) Is Positive Psychology?’, Review of General Psychology, 9: 103-110 Grant, AM and Spence, GB 2010, ‘Using Coaching and Positive Psychology to Promote a Flourishing Workforce: A Model of Goal-Striving and Mental Health’ in PA Linley, S Harrington and N Page (Eds) Oxford Handbook of Positive Psychology and Work, Oxford: Oxford University Press, 175-188 Green, S and Spence, GB (in press), ‘Evidence-Based Coaching as a Positive Psychology Intervention’ in AC Parks (Ed.) The Wiley-Blackwell Handbook of Positive Psychological Interventions, New York: John Wiley & Sons Inc. Jahoda, M 1958, Current Concepts of Positive Mental Health, New York: Basic Books Inc. Keyes, CLM 2007, ‘Promoting and Protecting Mental Health as Flourishing: A Complementary Strategy for Improving National Mental Health’, American Psychologist, 62: 95-108 Keyes, CLM and Lopez, SJ 2002, ‘Toward a Science of Mental Health: Positive Directions in Diagnosis and Interventions’, in CR Snyder and SJ Lopez (Eds) The Wiley-Blackwell Handbook of Positive Psychology, New York: Oxford University Press, 45-59 Layous, K, Chancellor, J, Lyubomirsky, S, Wang, L, and Doraiswamy, PM 2011, ‘Delivering Happiness: Translating Positive Psychology Intervention Research for Treating Major and Minor Depressive Disorders’, Journal of Alternative and Complementary Medicine, 17: 1-9 Linley, PA and Joseph, S 2004, ‘Applied Positive Psychology: A New Perspective for Professional Practice’ in PA Linley and S Joseph (Eds) Positive Psychology in Practice, Hoboken, NJ: John Wiley & Sons Inc., 3-12 Miller, GA 1969, ‘Psychology as a Means of Protecting Human Welfare’, American Psychologist, 24: 1063-1075 Noble, T and McGrath, H 2008, ‘The Positive Educational Practices Framework : A Tool for Facilitating the Work of Educational Psychologists in Promoting Pupil Wellbeing’, Educational and Child Psychology, 25: 119-134 Ryff, CD and Keyes, CLM 1995, ‘The Structure of Psychological Well-Being Revisited’, Journal of Personality and Social Psychology, 69: 719-727 Seligman, MEP, Steen, T, Park, N and Peterson, C 2005, ‘Positive Psychology Progress: Empirical Validation of Interventions’, American Psychologist, 60(5): 410-421 Seligman, MEP, Rashid, T and Parks, AC 2006, ‘Positive Psychotherapy’, American Psychologist, 61: 774-788 Seligman, MEP 2007, ‘Coaching and Positive Psychology’, Australian Psychologist, 42(4): 266-267 Seligman, M, Ernst, R, Gillham, K and Linkins, M 2009, ‘Positive Education: Positive Psychology and Classroom Interventions’, Oxford Review of Education, 35(3): 293-311 Seligman, MEP 2011, Flourish, NewYork: Simon & Schuster Sheldon, KM and Lyubomirsky, S 2006, ‘How to Increase and Sustain Positive Emotion: The Effects of Expressing Gratitude and Visuali sing Best Possible Selves’, The Journal of Positive Psychology, 1: 73-82 Sin, NL and Lyubomirsky, S 2009, ‘Enhancing Well-Being and Alleviating Depressive Symptoms with Positive Psychology Interventions: A Practice-Friendly MetaAnalysis’, Journal of Clinical Psychology: In Session, 65: 467-487 Dr Suzy Green is a clinical and coaching Psychologist (MAPS) based in Sydney. She is a leader in the complementary fields of Coaching Psychology and Positive Psychology having conducted a world-first study on evidence-based coaching as an Applied Positive Psychology.

She was the recipient of an International Positive Psychology Fellowship Award and is published in the Journal of Positive Psychology. Suzy lectures on Applied Positive Psychology as an Adjunct Lecturer in the Coaching Psychology Unit, University of Sydney and is an Honorary Vice President of the International Society for Coaching Psychology and a Visiting Senior Fellow of the Sydney Business School, University of Wollongong. She is also the Founder of The Positivity Institute, an organisation dedicated to the research and application of Positive Psychology for life, school and work, and writes a regular ‘stress-less’ column for Australian Women’s Health magazine.

CQ: The CAPA Quarterly

(continued from Page 21)

With training in these creative approaches, clinicians can use them as adjuncts to their existing practices. Boundaries and ethics must always be observed, and clinicians need to be aware of their own limitations in these areas.

A trained clinician using these approaches needs to have assessments and previous histories of each choir member and individual doing vocal improvisation. Such background gives the clinician a clear understanding of each person’s past experiences, the musical themes and song lyrics likely to evoke a painful response, and the best appropriate interventions.

For clinicians without music therapy training, a collaboration with a music therapist registered with the Australian Music Therapy Association would offer the best opportunity for successful outcomes.

References Aiello, L and Dunbar, R 1993, ‘Neocortex Size, Group Size and the Evolution of Language’, Current Anthropology, 34: 184-93 Alexopoulos, G 1988, ‘Cornell Scale for Depression in Dementia’, Biological Psychiatry, 23 (3): 271-284 Austin, D 2001, ‘In Search of the Self: The Use of Vocal Holding Techniques with Adults Traumatized as Children’, Music Therapy Perspectives, 19 (1): 22-30 Beck, A, Steer, RA and Brown, GK 1996, Manual for the Beck Depression Inventory-II, San Antonio, TX: Psychological Corporation 1: 82 Bowlby, J 1979, The Making and Breaking of Affectional Bonds, London: Tavistock Publications Limited Budzinski, T, Budzinski, H, Evans, J and Ababarnel, A 2009, Introduction to Quantitative EEG and Neurofeedback, Burlington, CA: Academic Press Cahn, R and Polich, J 2009, ‘Meditation (Vipassana) and the P3a Event Related Brain Potential’, International Journal of Psychophysiology, 72: 51-60 Chang, R and Thompson, N 2011, ‘Whines, Cries and Motherese: Their Relative Power to Distract’, Journal of Social Evolutionary and Cultural Psychology 5 (2): 10-20 Clift, S and Hancox, G 2001, ‘The Perceived Benefits of Singing’, Journal of the Royal Society for the Promotional of Health, 121(4): 248-256 Clift, S and Hancox, G 2010, ‘Choral Singing and Psychological Wellbeing: Quantitative and Qualitative Findings from English Choirs in a Cross-National Survey’, Music Performance Record 3(1): 79-96 Cohen, G 2006, ‘Research on Creativity and Aging: The Positive Impact of the Arts on Health and Illness’, Generations Journal of the American Society on Aging, 30(1): 7-15 Cooper, R, Abraham, J, Berman, S and Staska, M 1997, ‘The Development of Infants’ Preference for Motherese’, Infant Behavior and Development, 20(4): 477-488 Cozolino, L 2008, The Healthy Aging Brain: Sustaining Attachment, Attaining Wisdom, New York: WW Norton & Company Daaleman, T and Frey, B 2004, ‘The Spirituality Index of Well-Being: A New Instrument for Health-Related Quality-of-Life Research’, The Annals of Family Medicine, 2(5): 499-503 Davis, L 2005, ‘Educating Individuals with Dementia’, Topics in Geriatric Rehabilitation, 21(4): 304-314 Fachner, J, Gold, C and Erkkila, J 2012, ‘Music Therapy Modulates Fronto-Temporal Activity in Rest-EEG in Depressed Clients’, Brain Topography, 1-17 Folstein, M, Folstein, S and McHugh, P 1975, Mini-Mental State: A Practical Method for Grading the Cognitive State of Patients for the Clinician, Oxford: Pergamon Press Genevsky, A, Garrett, C, Alexander, P and Vinogradov, S 2010, ‘Cognitive Training in Schizophrenia: Neuroscience-Based Approach’, Dialogues in Clinical Neuroscience, 12(3): 416 Hodges, D 2000, ‘Implications of Music and Brain Research’, Music Education Journal Special Focus Issue: Music and the Brain, 87(2): 17-22 Im, S and Shin, C 2011, ‘The Effects of Music on the Frontal EEG Asymmetry of the Mothers with Postpartum Blues’, Korean Journal of Biological Psychiatry, 18(3): 134-140 Kingston, T, Dooley, B, Bates, A, Lawlor, E and Malone, K 2007, ‘MindfulnessBased Cognitive Therapy for Residual Depressive Symptoms’, Psychology and Psychotherapy: Theory, Research and Practice, 80:193-203 Koelsch, S 2009, ‘A Neuroscientific Perspective on Music Therapy’, Annals of the New York Academy of Sciences, 1169: 374-384 Kraus, N and Chandrasekaran, B 2010, ‘Music Training for the Development of Auditory Skills’, Nature Reviews Neuroscience, 11(8): 599-605 Kreutz, G, Bongard, S, Rohrmann, S, Hodapp, V and Grebe, D 2004, ‘Effects of Choir Singing or Listening on Secretory Immunoglobulin A, Cortisol, and Emotional State’, Journal of Behavioral Medicine, 27(6): 623-635 Kropotov, J 2009, Quantitative EEG, Event-Related Potentials and Neurotherapy, San Diego, CA: Academic Press Laing, R 1960, The Divided Self, London: Penguin Books McGilchrist, I 2010, The Master and His Emissary: The Divided Brain and the Making of the Western World, New Haven: Yale University Press

February 2013

Mithen, S 2005, The Singing Neanderthals: The Origins of Music, Language, Mind and Body, London: Orion Publishing Co. Morgan, K, Harris, A, Luscombe, G, Tran, Y, Herkes, G and Bartrop, RW 2010, ‘The Effect of Music on Brain Wave Functioning During an Acute Psychotic Episode: A Pilot Study’, Psychiatry Research, 178(2): 446-448 Newham, P 1999, Using Voice and Song in Therapy: The Practical Application of Voice Movement Therapy, London: Jessica Kingsley Press Ochsner, K, Bunge, S, Gross, J and Gabrieli, J 2002, ‘Rethinking Feelings: An fMRI Study of the Cognitive Regulation of Emotion’, Journal of Cognitive Neuroscience, 14(8): 1215-1229 Robertson-Gillam, K 2008a, ‘Hearing the Voice of the Elderly: The Potential for Choir Work to Reduce Depression and Meet Spiritual Needs in Ageing, Disability and Spirituality’, in E MacKinlay (Ed.) Addressing the Challenge of Disability in Later, Jessica Kingsley Press: 163-182 Robertson-Gillam, K 2008b, ‘The Effects of Singing in a Choir Compared with Participating in a Reminiscence Group on Reducing Depression in People with Dementia, thesis viewed at http://handle.uws.au:8081/1959.7/35610 Robertson-Gillam, K 2011, ‘Music Therapy in Dementia Care’, in H Lee and T Adams (Eds) Creative Approaches in Dementia Care, Basingstoke, GB: Palgrave Macmillan Shioda, S, Homma, I and Kato, N (Eds) 2009, Transmitters and Modulators in Health and Disease: New Frontiers in Neuroscience, Tokyo: Springer Verlag Japan Siegel, D 2007, The Mindful Brain, New York: WW Norton Skevington S, Lofty M and O’Connell K 2004, ‘The World Health Organization’s WHOQOL-BREF Quality of Life Assessment: Psychometric Properties and Results of the International Field Trial’, a report from the WHOQOL Group, Quality of Life Research, 13: 299-310 Spinelli, E 2001, The Mirror and the Hammer: Challenges to Therapeutic Orthodoxy, London: Sage Publications Strait, D, Kraus, N, Skoe, E and Ashley, R 2009, ‘Musical Experience and Neural Efficiency: Effects of Training on Subcortical Processing of Vocal Expressions of Emotion’, European Journal of Neuroscience, 29(3): 661-668 Tonneitjck, H, Kinebbanian, A and Josephsson, S 2008, ‘An Exploration of Choir Singing: Achieving Wholeness Through Challenge’, Journal of Occupational Science, 15 (3): 173-189 Trainor, L and Trehub, S 1992, ‘A Comparison of Infants’ and Adults’ Sensitivity to Western Musical Structure’, Journal of Experimental Psychology: Human Perception and Performance, 18(2): 394 Ullrich, P and Lutgendorf, S 2002, ‘Journaling About Stressful Events: Effects of Cognitive Processing and Emotional Expression’, Annals of Behavioral Medicine, 24(3): 244-250 Warnock, T 2011, ‘Voice and the Self in Improvised Music Therapy’, British Journal of Music Therapy, 25(2): 32-47 Winnicott, D 1971, Playing and Reality, London: Routledge

Kirstin Robertson-Gillam, MA(Hons), MCouns, RN, RMT, PhD candidate (UWS) is a registered nurse (general and midwifery), a registered music therapist, a registered psychotherapist/counsellor, and a NSW WorkCover provider. She is in the final stages of writing her PhD dissertation, which describes the effects of her choir support program on depression and using brain wave measurements in the pilot study to test the effectiveness of the program in middle-aged, community-dwelling adults. Kirstin is keen to introduce other practitioners to vocal improvisation and the choir program as an adjunct to their counselling and psychotherapy practices.

She has a psychotherapy counselling practice in north-west Sydney and conducts workshops on dementia care, choir therapy and positive psychology. kirstinrg@bigpond.com, www.kirstinrg.com

Michael Atherton is Professor of Music at the University of Western Sydney. He is recognised internationally for his musical innovation, his knowledge of diverse musical instruments, and research supervision in music therapy and wellbeing. Michael has a track record in artistic direction, acoustic and electroacoustic music, and improvisation—all with an experimental focus drawing on industry experience as a composer, performer and artistic director.

Leon Petchkovsky is an Associate Professor of Psychiatry with University of Queensland, the Director at Pinniger Clinic, Consultant Neuropsychiatrist in Child and Adolescent Mental Health at Solstice-Mind Matters and a Visiting Specialist at SONT Central Australia. Leon is a Past President of Australian and New Zealand Association of Jungian Analysts ANZSJA, and he is interested in brain imaging studies of psychotherapy processes.

35

Noticeboard

Calls for Contributions November 2013 – The Profession Every therapist and counsellor faces common challenges and issues in their practice that are specific to the profession. In this issue we invite you discuss the needs, challenges and issues therapists and counsellors face as normal hazards of the profession. How do we prevent burnout, find the time and discipline to ensure adequate supervision, maintain a steady client base while achieving a worklife balance, stay current and ensure that you are ‘good enough’? The November issue of CQ: The CAPA Quarterly offers a forum for exploration of these and other questions about the personal side of being a therapist or counsellor. Step forward and have your say.

Peer-reviewed papers due by: 1 May

Non-peer-reviewed due by: 1 August

February 2014 – Open Forum Do you have an insight to share about the practice of therapy, but haven’t been able to align it with any of the announced themes for CQ: The CAPA Quarterly? Now we have an Open Forum each February so that articles on any aspect of therapeutic practice can be welcomed. Share your knowledge with your peers and open up discussion on topics of importance to you.

Peer-reviewed papers due by: 1 August

Non-peer-reviewed due by: 1 November

May 2014 – Mindfulness and Spirituality Mindfulness is often thought of in relation to spirituality, given its roots in esoteric traditions; however, therapeutic models are increasingly incorporating a range of approaches focussing on mindfulness and acceptance due to a growing body of research suggesting that mindfulness-based therapies may be effective in treating a variety of disorders including stress, chronic pain, depression and anxiety. In this issue, we will explore the historical and philosophical roots of mindfulness therapies, theoretical underpinnings, specific applications, and mindfulness treatment strategies—and how they might also relate to spirituality. We invite you to share in this exciting discussion by contributing to the May issue of CQ. Peer reviewed papers due by: 1 November

Non-peer-reviewed due by: 1 February

August 2014 – Cross-Cultural Issues in Counselling In this issue of CQ, we critically reflect upon the major concerns and sensitivities underlying issues of race and culture, and the impact they can have on relationships in counselling and psychotherapy. How can the cultural backgrounds of both the counsellor and client affect the therapeutic process? How do we become more culturally aware? What are the issues and what steps should we be taking to better prepare ourselves to meet the culturally diverse challenges faced in today’s therapy rooms? Share your professional insights and experiences surrounding the development of culturally sensitive counselling and cross-cultural awareness in the August 2014 issue of CQ. Peer reviewed papers due by: 1 April

Non-peer-reviewed due by: 1 May

Deadlines are for articles that have been accepted, not for new ideas.

Please send expressions of interest as soon as possible, to maximise your chance of inclusion.

For Contributor Guidelines contact editor@capa.asn.au

Advertising rates for 2013 Ad size Four Colour (available only full page) Inside front or inside back cover

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Book your ad for a year (4 issues) and receive a 12% discount Booking deadlines February issue 1 December May issue 1 March August issue 1 June November issue 1 September Artwork/copy deadlines February issue 1 January May issue 1 April August issue 1 July November issue 1 October

For advertising specifications and bookings, contact our Advertising Coordinator at: advertising@capa.asn.au or 02 9235 1500

36

CQ: The CAPA Quarterly

Classifieds

A free service for CAPA NSW members, contact advertising@capa.asn.au

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Supervision Supervision – Phone or Skype Counsellor, supervisor, group facilitator, with 16 years’ experience. CMCAPA, RMPACFA, ARCAP Registered (Clinical), PACFA Accredited Supervisor, Cancer Counselling Professional. Speciality areas include anxiety, depression, grief/loss, death/dying, same-sex, carers, young carers, pain management, adults surviving child abuse, relationships, spirituality, group facilitation. Contact Erica Pitman, Bathurst, NSW 6332 9498 or email ericap@ix.net.au Supervision – Burwood & Dulwich Hill Individual and group supervision for counsellors, group leaders and those supporting people with a

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CQ: The CAPA Quarterly – Peer-Reviewed Articles

Submitting your articles for peer review has many benefits, including: elevating the quality and authority of your work expanding your Higher Education Research Data Collection (HERDC) publication count enhancing the academic rigour of The CAPA Quarterly CQ uses a double-blind review process, where the identities of both author(s) and reviewers remain anonymous. Articles submitted for peer review will be sent to 2–3 independent reviewers.

Guidelines for your submissions with a request for peer review are available by contacting editor@capa.asn.au February 2013

37

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Journal of the Counsellors and Psychotherapists Association of NSW Inc ABN 50 035 123 804 If undeliverable, please return to: CAPA NSW Suite 134 / Level 13 183 Macquarie Street Sydney NSW 2000 Phone: +61 2 9235 1500 Email: office@capa.asn.au Web: www.capa.asn.au Changed your address?

Please notify CAPA NSW

Looking for a Conference?

To include your free conference listing here, contact editor@capa.asn.au 21-24 February 2013 Melbourne 25-26 February 2013 Singapore 1-2 March 2013 Melbourne 2 March 2013 London

Looking for a conference? Some prominent psychology conferences in Australia and elsewhere this year are listed below. For a more comprehensive list of psychology conferences worldwide, visit http://www.conferencealerts.com/psychology.htm

APS Counselling Psychology Conference Evidence-Based Approaches To Practice 2nd Annual International Conference on Cognitive and Behavioral Psychology Mindfulness Science and Practice: An International Conference UK Council for Psychotherapy Annual Supervision Conference

http://www.groups.psychology.org.au/ccoun http://www.cognitive-behavior.org http://www.mindfulness.conorg.com.au/ http://www.psychotherapy.org.uk/event1737.html

1-3 March 2013 New York

‘Wounds of History: Repairing Transgenerational Transmission of Trauma’ Conference

http://www.postdocpsychoanalytic.as.nyu.edu/page/events-calendar

4-7 March 2013 Lima, Peru

5th World Congress on Women's Mental Health

http://www.iawmh.org/congress.html

6-9 March 2013 Athens

International Congress on the Psychosocial Consequences of Disasters

19-23 March 2013 Stellenbosch, South Africa

1st World Conference on Personality

28-31 March 2013 Osaka

The Third Asian Conference on Psychology and the Behavioral Sciences

4-6 April 2013 Singapore

Somatic Integration: Restoring the Body Wisdom

11-15 April 2013 Arlington, VA 18 April 2013 Fremantle 13-19April 2013 Philadelphia 26-28 April 2013 Syracuse, New York 18 May 2013 Melbourne

American Society of Group Psychotherapy and Psychodrama (ASGPP) 71st Annual Conference 2013 APS Forensic Psychology Conference 14th Annual International SCT Conference ‘Freeing Energy for Change’ The 2013 Empathic Therapy Conference Melbourne Freud Conference 2013

http://psychcongress2013.gr/en http://www.perpsy.org/ http://www.acp.iafor.org/ http://www.psychologymatters.asia/event/246/ somatic-integration-restoring-the-body-wisdom http://www.asgpp.org http://www.psychology.org.au/events/EventView. aspx?EventID=11069&Highlight=1 http://www.systemscentered.com/sctconference http://www.empathictherapy.org/Conference.html http://www.freudconference.com/

1-2 June 2013 Sydney

Australian Yoga Therapy Conference (AYTC) 2013

http://www.enlightenedevents.com.au/events/ australianyogatherapyconference2013

5-7 July 2013 Moscow

The First United Eurasian Congress for Psychotherapy

http://www.eurasian-psychotherapy.com/main-en.html

8-12 July 2013 Sydney

ACBS World Conference XI

10-13 July 2013 Brisbane

Society for Psychotherapy Research (SPR) 44th International Annual Meeting

http://anzact.com/ http://www.psychotherapyresearch.org/calendar.cfm

22-25th July 2013 Lima, Peru

7th World Congress of Behavioural and Cognitive Therapies

5-6 August 2013 Gold Coast

14th International Mental Health Conference

http://anzmh.asn.au/conference/

23-24 August 2013 Melbourne

11th Annual Conference of the Australia & New Zealand Academy for Eating Disorders

http://conference.anzaed.org.au/

24-25 August 2013 Brisbane

2013 AABCAP Annual Conference

http://www.aacbt.org/viewStory/INTERNATIONAL+EVENTS

http://www.buddhismandpsychotherapy.org/ events/annual-conference