Article by Anna Keyter
BY: Online Therapy
Anxiety / Anxiety counselling / Anxiety therapy / Online Anxiety Therapy
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Article by Anna Keyter and Marvis Bih
What is anxiety?
Anxiety is a normal reaction when a person feels threatened, under pressure when faced with challenging circumstances. Someone may feel anxious before, during or after sitting an exam, going for a job interview or facing a hospital procedure (Smith, Robinson & Segal, 2021). The degree of anxiety differs with the level of risk or trauma involved.
Hence, anxiety is an emotional state that can work for us or against us. For instance, the flight response is useful when we are chased by a lion because the spike in adrenalin will help us run faster, be more alert and get us out of a dangerous situation. This response is evolutionary and is important for our survival.
However, the flight response is not useful when we are reminded of previous traumas which could lead to a heightening of feelings of anxiety. Although we all experience anxiety responses, we often differ in how we perceive the triggers and how we respond to them (Mental Health Foundation, 2014).
Response to triggers
Rape Crisis, (England and Whales) categorises feelings of anxiety as fight, flight, flop, freeze or friend response. These responses are triggered when we believe we are in a high-risk situation and react to life-threatening danger. Immediate responses may include increased heart rate and breathing, sweating, tightening our muscles and an adrenaline rush that gives us a burst of energy. Furthermore, cortisol is released to relieve pain at the moment of danger which could block rational thinking. People who live in times of extreme stress and fear sometimes experience feelings such as brain fog or having an inability to concentrate.
The Sexual Assault Crisis Centre lists 5 F’s of Trauma Response:
- Fight: Feelings of anger and rage. Physical fights, struggle or pushing someone away.
- Flight: Spacing out, hiding, running or backing away from the danger.
- Freeze: Panic, numb-out, standing still.
- Flop: To protect oneself, the mind might automatically shut down. Muscles go numb and a person could fall.
- Friend: Calling to others for help and/or ‘befriending’ the perpetrator by pleading or negotiating with them.
Everyone has experienced anxiety at some point. Depending on the level of trauma, triggers can persist until effective coping strategies are learned (Mental Health Foundation, 2014).
Clinicians can use the DASS (Depression Anxiety Stress Scale) as a screening tool to measure Anxiety and Acute Stress Disorder. In clinical settings, the DASS-21 incorporates the clients’ self-reported emotional disturbance as part of the broader assessment. In this way, the clinician can assess the severity of symptoms of depression, anxiety and stress (Shea, Tennant & Pallant, 2009).
Signs and symptoms of anxiety
Apart from irrational fear and worry, some primary and common symptoms of anxiety may include, but are not limited to;
- Poor concentration
- Feeling of dread
- Consistently looking for signs of danger
- Anticipating the worst outcome
Psychologists note that anxiety could be more than just a feeling (Smith, et al., 2021). It could include a range of physical symptoms such as
- Shortness of breath
- Pounding heart
- Stomach upset
There are different types of anxiety disorders such as panic attacks, generalized anxiety disorder (GAD), social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PSTD), hoarding disorder, separation anxiety and phobias (Smith, et al., 2021; Mental Health Foundation, 2014).
Online Therapy: Responding to Anxiety
It is important to note that anxiety is not an illness but can be a devastating condition. Anxiety CARE UK (2018) notes that “a person cannot just simply decide not to be anxious anymore”. This is because anxiety affects normal human functioning and people need to develop strategies to cope with it. There are some good self-help strategies that can be useful to lower anxiety and manage symptoms of anxiety. These include:
- Deep breathing
- Regular exercise
- Yoga or meditation
- Getting enough sleep
- Watch caffeine, nicotine and alcohol intake
- Learn to connect with others especially if loneliness triggers or worsening symptoms
- Practice relaxation techniques (Smith, et al., 2021; Anxiety CARE UK, 2018)
These self-help strategies are less likely to work in the case of an acute disorder. In acute circumstances, it is important to seek professional help such as Cognitive Behavioral Therapy, Exposure Therapy, and in severe cases, medication can be administered (Mental Health Foundation, 2014). Similarly, free-floating (or chronic) anxiety may resolve more quickly with professional help.
Online Therapy: Responding to Anxiety – If you feel you would like tome professional help in working through your anxiety, feel free to contact us:
Anxiety CARE UK. (2018). Anxiety. Ciara healthy thoughts. Available at: https://ciarashealthythoughts.wordpress.com. Accessed 30th March 2021.
Smith, M., Robinson, L. & Segal, J. (2021). Anxiety disorder and anxiety attacks. Available at: https://www.helpguide.org. Access 29 March 2021.
BY: Online Therapy
Anxiety / Depression / Post Traumatic Stress Disorder / PTSD / Trauma
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Article by Marvis Bih,
What is PTSD?
Post-Traumatic Stress Disorder refers to a severe anxiety disorder that a person develops after being exposed to one or more serious life situations that result in deep psychological trauma (Nicholls, et al., 2006). Persons suffering from PTSD may have difficulty engaging in interpersonal relationships, have flashbacks and experience paranoia. Anyone can develop PTSD and it can happen at any age.
What causes PTSD?
Some causes of PTSD include witnessing serious physical, sexual and emotional abuse or assault (Spitzer, 2009), major man-made or natural disasters, war, genocides, major accidents, sicknesses or pandemics such as COVID-19 (Frans 2005). Many studies have linked PTSD with other comorbid psychiatric disorders (Gershuny, 2002; NIMH, 2020). In addition, some biological factors such as genes may make some people more likely to develop PTSD (NIMH, 2020).
Age and the effects of PTSD
Children and teenagers are more vulnerable to trauma and have extreme reactions. Symptoms in children may include but not limited to; unusually clingy with a parent, unable to talk and wetting the bed. However, older children often display symptoms like those seen in adults such as destructive behaviour, being disrespectful and disruptive (National Institute of Mental Health, 2020).
When to seek help
When a child or an adult’s symptoms last for a few weeks and not getting better, it is advisable to seek for help. A mental health counsellor or a trained therapist can recognise and treat trauma in children and adults, by addressing the root cause of the child’s behaviour and promote healing (Child Welfare Information Gateway, 2014).
The traumatic effect of COVID-19
The COVID-19 pandemic has affected the world, leading to nations shutting down their economy and services and people were encouraged to work from home. This situation created anxiety and mental stress for many people. Therefore, in these emotionally draining times, mental health practitioners need to be flexible in their approach to therapy.
Benefits of Online Therapy
The flexibility of Online Therapy means that practitioner can change the way they deliver therapy. With the age of technological advancement, we can now offer and receive therapy from the comfort of our homes through online therapy. Online therapy is different from face to face therapy, but certainly no less effective. Online therapy takes place online by connecting through technology such as smartphone, iPad, laptop or a desktop.
Online therapy platforms
There are different types of interventions used to deliver online trauma therapy. Methods include virtual technology such as Skype counselling or Zoom, telephone counselling, chats or a combination of any of these. More on online therapy and finding a good online therapist coming up next week. Join us next week as we explore online therapy, a good online therapist and how to find an online therapist.
Need to get hold of one of our psychologists? Please feel free to complete the form.
Gershuny B S, Baer L, Jenike M A, Minichiello W E, Wilhelm S. (2002). Comorbid posttraumatic stress disorder: impact on treatment outcome for obsessive-compulsive disorder. Am J Psychiatry, 159(5): 852-854.
Spitzer C, Barnow S, Volzke H, John U, Freyberger H J, Grabe H J. (2009). Trauma, posttraumatic stress disorder, and physical illness: findings from the general population. Psychosom Med, 71(9): 1012-1017.
BY: Online Therapy
Anxiety / Decisional Fatigue / Depression / Fatigue counselling
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By Sara Taveira
The anxiety of making choices
Today I decided to talk about the paradox of choices. I went to lunch at a restaurant with so many options on the menu; it made me anxious. I share my experience with you, dissected it from a Clinical and Health Psychology perspective to help get to an understanding of how the thought of “the more options we have the better”, is a great fallacy!
The menu offered more than 20 options for main courses and I felt the anxiety running through my body. The sweet anxiety of choice! The first consequence of this was mind-boggling, being confused without being able to read the name of all the dishes. I don’t need to explain how this increased my indecision, right? The truth is that it was really difficult to make a choice, without even realizing it. In fact, when I reflect on what happened, I now realize that my choice, like all of our choices, adds to anxiety on an unconscious level. In particular, here I was thinking about what others would think of my choices and even more, I ended up basing my choice on what I saw others selected.
Finally, I became aware of my anxiety about making choices and wondered if I had chosen the best meal. With so many options, my expectations naturally increased. When the meal finally arrived it was good, but I was disappointed because “I expected more”. Ultimately, I started to think that I made a mistake and felt guilty for not enjoying the meal as much as I could. That, of course, made me even more anxious and frustrated with myself. Do you notice the endless loop? Now let’s translate my experience of eager gastronomic choice to Psychology.
How many choices do we make a day?
We make an average of 35000 choices per day, from deciding whether to take a step left or right, to the more complex professional decisions. The simpler choices come from a fast, automatic, and intuitive system in the brain instead of the complex choices, which arise from a slower, analytical and rational system that therefore expends a lot of brain energy.
The more choices we make in our day-to-day lives, the more tired our brain gets, especially if they are complex. And it is at this point that we feel daily wear and tear and may wonder if we are depressed or just fatigued. Don’t get confused. This lack of mental energy for making too many choices is called “decisional fatigue” which has the consequences of reducing our capacity for self-control, leads to inertia and automatic decisions accepted by the status quo. This explains why I froze and ended up ordering what others ordered.
This phenomenon also explains why we sometimes make so many “mistakes” later in the day. We may decide not to go to the gym because we are tired, we get home, lie on the couch, order fast food and we binge-watch our favourite series. Sound familiar? That is, the more decisions you make during the day, the more difficult it is to make good decisions at night, as your self-control diminishes, your brain becomes tired, just like our muscles after an hour of physical exercise.
How to prevent this decisional fatigue?
Basically, we have to work with these two systems that I explained and automate as many daily decisions as possible to save the most rational system for when it is necessary to avoid impulsive decisions and mistakes.
What do I want you to retain today? Choices imply risks, losses, and changes, and for that reason are unpredictable which undoubtedly goes hand in hand with anxiety. Leaving things to chance is intolerable and that is why we try our best to prevent the risk of this happening. But by stopping chance, we decrease our happiness because we do not allow ourselves the possibility of pleasant surprises. Even more serious, we are stuck with regret and dissatisfaction because it is impossible to arrive at the ideal choice which leads to feelings of guilt, inadequacy, and high self-criticism. Another way to increase anxiety. The choice is, then, the hesitation before the decision, which, when increased and diversified, can lead us to mental confusion, to feelings of constant doubt, which diminishes our self-confidence.
A Solution strategy
Why not try to understand your choices as clouds? For example, have you ever heard someone say that cloud format was good or bad? Never, right? So why don’t we also think that choices are just that, choices, possibilities and that they can’t be good or bad? If we take this stance, we cannot make catastrophic mistakes even when it seems that we did it when we chose A or B. The truth is that everything ends up being resolved in one way or another. Think back to a problem that seemed huge and impossible to solve at the time. The likelihood is that now you even smile when remembering how you exaggerated your fears and anxieties. Trust yourself, as there are many roads to the right path.
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BY: Online Therapy
Acceptance Commitment Therapy / Acceptance Commitment Training (ACT) / Anxiety / Group Therapy / Online ACT / Online therapist / Online Therapy / Workplace stress / Workshop
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Group Therapy using Acceptance Commitment Training ACT:
Good news! Online Therapy will be offering group counselling programmes starting next year (2019) mid-January. To learn more about our previous workshops, please follow this link. We have prepared a course that focuses on Acceptance Commitment Training (ACT) which works well with workplace stress and anxiety. The year kicks off with training programs that can provide you with tools to make a positive change to your work environment and family life.
We love group work because it offers members feedback to help recognise personal problems from different perspectives. Within the therapeutic context, it is comforting to hear that you are not alone and that many people have similar ways of processing thoughts. It is also reassuring to know that group therapy using acceptance and commitment training ACT has a proven track record to address stress and anxiety effectively.
You may ask: Why choose Group Therapy using acceptance and commitment training ACT?
ACT is based on six core processes, acceptance, cognitive defusion, present moment, self-as-context, values and committed actions as discussed below. During group work, you will learn how to work through these processes and create goals based on their values and then taking committed action. Below is a summary of the ACT core processes.
Acceptance and Commitment Training or (ACT) six core processes:
During group work, you will be provided with tools to learn how to accept difficult emotions instead of fighting them.
You will learn to change the way you interact with difficult thoughts by creating distance from emotions that are not useful. In that way, negative thoughts have less power over you.
By learning to be present you are more flexible in your actions and you can start to set goals, based on what is important to you (values). This happens by changing your internal language. Your new behaviour will be based on your describing events in a non-judgemental way. Hence, you become “self-as-process” and learn to defuse from ongoing, unhelpful thoughts and feelings.
Due to relational frames (I vs You, Now vs Then, and Here vs There), language shapes our perspective of the world. Being self-as-context you become aware of how you identify with past and future thoughts. During group therapy, you will learn techniques to help you become aware of your ‘flow of experiences’ and learn how to detach from unhelpful feelings. Even with shortcomings we can accept ourselves and live meaningful lives.
The group will set goals according to their values.
You will be encouraged to take action linked to their values to achieve goals. After each session, you will receive homework to help you action your goals.
If you would like to learn more about Group Therapy using Acceptance and Commitment Training (ACT), then feel free to contact me using the form below.
To receive more information on Group Therapy using Acceptance Commitment Training ACT, please feel free to subscribe to our newsletter.
Mostafa Heydari, Saideh Masafi, Mehdi Jafari,Seyed Hassan Saadat, and Shima Shahyad (2018), Effectiveness of Acceptance and Commitment Therapy on Anxiety and Depression of Razi Psychiatric Center Staff
BY: Online Therapy
Anxiety / Assessment / Counselling / Depression / Depression Anxiety Stress Scale (DASS) / Screening Tool / Skype Counsellor / Stress
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Skype counsellor discussing Depression Anxiety Stress Scale (DASS):
In this article, the Skype counsellor discussing Depression Anxiety Stress Scale (DASS) developed by Lovibond S.H. and Lovibond P.F. The Depression Anxiety Stress Scale (DASS) was developed to report on negative emotional states employing a bipolar scaling measure (four-point rating scale, 0-3). Previously referred to as the Self-Analysis Questionnaire (SAQ), DASS has two additions, DASS-21 and DASS-42. The DASS-42 (42 items) is recommended for clinical use and the shortened version DASS-21 (21 items) for research.
The DASS is a screening tool, not meant for diagnosis of mental disorders. In this essay, the DASS-21 will be discussed in terms of how it relates to Depression, Anxiety and Acute Stress Disorder. DASS-21 will also be considered in terms of its relevance in the New Zealand context, psychometric properties, functions and limitations and ethical concerns.
Summarised from Lovibond & Lovibond, (1995a), DASS highlights three different negative states; the scales are not independent of the other. The authors used 30 samples that revealed three distinct scales which were labelled as Depression, Anxiety and Stress. They found that the internal consistency of the anxiety scale was consistently lower than stress and depression. However, it was an acceptable result to make inferences about individuals and groups.
The DASS-21 scales scored lower for internal consistency than DASS-42 due to the fact that it contained fewer items. However, it was within an acceptable range creating a balance between adequate consistency and adequate breadth of the measurement. The DASS-42 has a score range of 0-42 for each subscale which was upheld in a variety of populations, so does the DASS-21 since the scores are multiplied by two.
The initial development of the DASS was to differentiate between depression and anxiety. Utilising a factor analysis (the way observed correlated variables relate to unobserved variables), the DASS was administered to psychology students to identify items for the scales, depression and anxiety. A factor analysis arranges, in order of importance, values of observed data expressed as functions of possible causes.
Skype counsellor discussing Depression Anxiety Stress Scale (DASS) Relevance to New Zealand
A vast number of studies have been conducted in New Zealand (broader population) using the DASS to identify associations with depression, anxiety and stress (Robinson, Brocklesby, Garisch, et al., 2017; Kaplan, et al., 2015; Lovell, Huntsman & Hedley-Ward, 2014; Carter et al., 2014; King, 2014; Hunt, 2012; Samaranayake & Fernando, 2011; Rucklidge & Blampied, 2011).
According to the 2011/2012 New Zealand Health Survey, 14.3% of New Zealanders were diagnosed with depression at some point in their lives. Anxiety disorders also scored high, over 6.1% had disorders which include post-traumatic stress disorder (PTSD), generalised anxiety disorder (GAD), phobia and obsessive-compulsive disorder (OCD). Women scored higher than men. The diagnosis for women was 7.9% depression and 7.7% anxiety disorder v.s. 10.4% and 4.4% for men respectively. The 2012/13 Health Survey further indicates that 17.1% of deprived New Zealand adults have been diagnosed with a mental disorder, including bipolar/depression and/or anxiety disorder at some stage in their lives. This is 1.6 times higher than adults in less deprived areas. The Ministry of Health (2013) recorded for the period 2009-2013 that 1.7% (508) deaths in 2013 were suicides, with rates highest amongst Māori males,15-24. The Māori male youth suicide rate was almost twice that of Māori female, Pacific Islanders and other Asian ethnic groups as a due to stress that comes with stressors of economic and other deprivation.
Mental Health Issues
New to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the integration of a dimensional assessment (quantifying emotional states with scores) to the categorical approach (previously strictly categorical) (American Psychiatric Association [APA], 2013). DASS is not categorical, but a dimensional assessment based on a self-report of experiences within the past week (Lovibond & Lovibond, 1995a).
To derive a DSM-5 diagnosis during a clinical assessment, ensure that symptoms of each disorder are not attributable to a medical condition or better defined by another disorder. For a DSM-5 diagnosis, the episode should cause significant distress or impairment in social, occupational or essential areas of functioning (APA, 2013). The DASS timeframe for diagnosis falls outside of the DSM-5 Depression and Anxiety specification.
Major Depressive Mood Disorder must include at least five symptoms associated with criteria A in the DSM-5 presenting in a 2-week period and a change from previous functioning including one of the symptoms (1) depressed mood or (2) loss of interest/pleasure (APA, 2013). When considering the DASS-21 questions, depression is covered by items 3 (no positive feelings), 5 (difficulty doing things), 10 (nothing to look forward to), 13 (down-hearted), 16 (no enthusiasm), 17 (worthlessness), and 21 (meaninglessness), (Appendix A). These questions relate to negative effect.
Generalised Anxiety Disorder (GAD) includes excessive anxiety and worry occurring more often than not for at least six months and affects activities such as work or school performance and is associated with three or more of category C in the DSM-5 diagnostic manual (APA, 2013). The DASS-21 questions that relate to anxiety include question 2 (mouth dryness), 4 (breathing difficulty), 7 (trembling), 9 (worry), 15 (panic), 19 (heart rate) and 20 (scared for no good reason) (Appendix A). These questions cover physiological arousal.
Acute Stress Disorder (ACD) lasts at least three days to one month after trauma exposure, and the timeframe corresponds to the DASS-21 (identify items within the past week). To diagnose ACD the client should present with at least 9 symptoms from the 5 categories found in the DSM5 (APA, 2013). Questionnaire items on the DASS that cover stress include cognitive, subjective symptoms of anxiety including scale items 1 (difficulty winding down), 6 (over-react to situations), 8 (using nervous energy), 11 (agitation), 12 (difficult to relax), 14 (intolerant), and 18 (touchy).
Functions and Limitations of the Measure
Functions of the DASS-21
In clinical settings, the DASS-21 incorporates the clients’ self-reported emotional disturbance as part of the broader assessment. In this way, the clinician can assess the severity of symptoms of depression, anxiety and stress (Shea, Tennant & Pallant, 2009). Lovibond and Lovibond (1995a) stressed that the DASS-21 should not replace a clinical interview and that other disturbances not addressed by the scales should be identified through a clinical discussion. Furthermore, the scale has no direct implications for allocating diagnostic categories according to classification systems such as the DSM (Diagnostic and Statistical Manual of Mental Disorders) and ICD (International Classification of Disorders).
Reliability and Validity.
The DASS-21 normative data were based on one sample comprising 717 people between the ages of 17-69 years and found to be reliable. Alpha values (significant levels) for the 7-item normative sample scales were Depression 0.81, Anxiety 0.73, Stress 0.81. The factor structure (correlation between variables that measure a particular construct) and relative performance of individual items were found virtually the same in clinical and non-clinical samples and correlated highly to that reported by Beck (1988) on a clinical sample (Lovibond & Lovibond,1995b). Depression, anxiety and stress manifested by clinical outpatients and normal non-clinical groups differed primarily in severity. The results add to evidence suggesting that emotional disorders fall on a continuum with less extreme emotional disturbance where clinical disorders may represent the severe, inappropriate or chronic manifestation of syndromes (Lovibond & Lovibond,1995a). The scales are moderately inter-correlated at approximately rs= .5 – .7 which is in line with the BDI (Beck Depression Inventory) and BAI (Beck Anxiety Inventory).
Lovibond and Lovibond(1995b) made a comparison between the DASS, Beck Depression Inventory (BDI) and Beck Anxiety Inventory. They found that the anxiety scales were highly correlated (66% common variance r=0.81) and depression scales somewhat less correlated (55% r=.74). The lower cross-construct correlations between DASS and BDI scales (r=0.58 and r=0.54) indicate that there is a greater degree of convergent validity than in typically observed self-report scales.
The factor analysis was indicated as the primary reason for the lower correlation between DASS Depression and BDI, due to BDI’s inclusion of somatic symptoms, i.e. loss of libido, appetite, weight loss etc. and anxiety loss of sexual interest, loss of appetite, weight gain, increased sleep. The DASS correlates well with the Personal disturbance scale, Positive & Negative Affect Schedule, Hospital Anxiety and Depression Scale (Osman, Wong, Bagge, et al., 2012).
Researchers found the DASS-21 to be valid, reliable and easy to administer for both clinical and research purposes (Osman, Wong, Bagge, et al., 2012; Norton, 2007; Henry, Crawford, 2005; Crawford & Henry, 2003). Additional studies replicated the psychometric properties (Da Silva et al. 2016; Tran et al. 2013; Nieuwenhuijsen et al., 2003; and more).
Administration and Scoring.
Both DASS questionnaires (21 and 42) are public domain, and no special skills are required to administer the self-report instruments. However, interpretation should be carried out by professionals. The DASS-21 can be conducted manually, online or via computer. Note that professionals do not have permission to administer the DASS on a website or app open to the public. The scale’s administration is restricted to defined groups, clients or participants in research. Electronic administration for research purposes can be automated for scoring (Lovibond & Lovibond, 1995a).
It is recommended to administer the DASS-21 during the first interview and again after treatment to measure the significance of outcomes (Ronk, Korman, Hooke, & Page, 2013). Through the DASS-21 tool, depression, anxiety and stress are measured dimensionally varying on a continuum of severity ranging between 0-3 as follows (Appendix A):
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of the time
3 Applied to me very much, or most of the time
Included in the DASS Manual, clinicians receive a plastic scoring template to place over the completed response form. Scale information, i.e. D (Depression), A (Anxiety) and S (Stress) are listed alongside the rating scales, sum scores for each scale and multiply DASS-21 scores by two (Appendix B). DASS scores can be interpreted using the DASS-21 profile sheet to enable comparisons between the scales (Appendix C) (Lovibond & Lovibond, 1995a). Table 1 is a breakdown of the severity rating from normal to extremely severe.
Even though DASS scores should not be used exclusively to assess depression, anxiety or stress, high scores would alert clinicians of high levels of distress that could be explored further during an interview. During additional DASS administrations, changes in one scale (i.e. depression) and consistently high scores in another (i.e. anxiety) could inform a clinician to pay attention to co-existing anxiety, other problems or life-events that could be directly addressed in therapy (Lovibond & Lovibond, 1995a).
The DASS had over 25 translations available (Parkitny & McAuley, 2010) and was validated in numerous contexts including generational and racial groups (Norton, 2007). The measure is also widely used internationally (Oei, Sawang, Yong, & Mukhtar, 2013). Furthermore, the DASS was applied to older persons (Gloster, et al., 2008), children and adolescents (Szabó & Lovibond, 2006; Szabó, 2010; da Silva et al., 2016), from military veterans (MacDonell, Bhullar & Thorsteinsson, 2016) to validating the DASS-21 as screening tool in rural northern Vietnamese women (Tran, Tran & Fisher, 2013).
Limitations of the DASS-21
When using self-report questionnaires, psychologists rely on the honesty of participants. The DASS is unable to identify malingering (Lovibond & Lovibond, 1995a). Furthermore, people have different ways of completing forms; some prefer extreme points while others use midpoints, hence, completing questions may be unintentionally biased (Austin, Gibson, Deary, et al., 1998).
The DASS-21 is a screening tool for professionals to assess low or disturbed mood in clients. Caution is advised when using the scales since severity ratings were obtained from large, mostly heterogeneous samples of individual ratings. “The further away the score from a population mean the more severe the symptoms” (Parkitny & McAuley, 2010 p.204).
When considering risk, the DASS-21 does not assess suicidality. Risk assessment should be carried out during the clinical interview. According to Lovibond and Lovibond (1995a) items for suicidal tendencies were not found on any scale and an experienced clinician will recognise the need for a comprehensive risk assessment.
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For the article Skype counsellor discussing Depression Anxiety Stress Scale (DASS), below are useful references if you want to find out more.
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Article by Anna Keyter
Online Therapist Analysing InTreatment Week 4 | Sophie & Paul:
This article is a critical analysis of a therapy session based on an assessment of the HBO episode: In Treatment. (Disc Four) with Sophie and Paul. The purpose of the session was for Paul to write a report on Sophie’s suicidality. However, the assessment turned into therapy. Sophie presents self-harming behaviour, risky sexual activity and substance use.
Sophie was raped and exhibits the typical acting out behaviour of teenage rape victims. Signs of adolescent rape include conduct such as extreme agitation, anger outbursts, depression, sleep and school problems (NSOPW, n.d.). She also engages in alcohol misuse, promiscuity, eating disorder and running away from home and possibly comorbid depression (DSM5, 2013). Contextual variables, including transference-countertransference, will be discussed first, followed by the strategies Paul used to develop the therapeutic relationship. Ruptures will be addressed firstly by looking at ethical challenges that arose followed by ruptures due to cues Paul missed during the session. Each section describes behaviours/events and recommendations on the ruptures that occurred during the session.
The contextual variables will be discussed in terms of countertransference and transference experienced by Paul (therapist) and Sophie (client). From a psychodynamic perspective, countertransference can be defined as the therapist’s subconscious emotional reaction to the experiences of the client. Transference is when the client subconsciously redirects feelings for one person to the therapist. Gelso (2014) refers to a tripartite model of psychodynamic intervention, “asserting that all therapeutic relationships, to varying degrees, consist of a real relationship, a working alliance, and a transference-countertransference configuration”.
Paul | Countertransference
Paul, a middle-aged man with children, is providing therapy to Sophie, a teenage girl who was raped. Sophie’s experiences affect Paul. Countertransference is not necessarily bad and could serve as an internal barometer to assess personal reactions to social interaction when the psychologist is aware of it (Gelso, 2014). During my observation of the session, Paul seemed to assume an almost fatherly role in his interaction with Sophie which could be due to a subconscious need to act as a parent to her. Schaeffer (2007) expresses the importance for therapists to identify transference and countertransference as soon as possible for the therapist to be in control of it and not be controlled by it.
Hence, countertransference could be useful if Paul examines his reasons for the way he behaves. Even though Paul is a psychodynamic therapist, I am uncertain if he is aware of his emotions of countertransference. Paul should pursue personal therapy to distinguish reasons for the countertransference that was evoked by Sophie throughout the session. In particular, Paul reacted strongly when Sophie’s commented on the gymnast that told her sex with her was like having sex with someone who had been sexually abused. Paul responded by saying “Prick”. At one stage Paul also tried to comfort Sophie by putting his arm around her and stroking her shoulder and hugging her (which could have ethical implications).
Sophie | Transference
Sophie is a teenage girl who was referred to Paul after a bicycle accident that was possibly a suicide attempt. She has a strained relationship with her mother and only mentioned her father once. She is a hopeful Olympic level gymnast. However, she had been sexually abused by her coach Sy. Initially, the relationship with Sy’s family seemed close; she spent time at their house, babysitting their daughter Dena.
Sophie was on Sy’s bicycle the night of the accident, and it should have been Paul’s intention to assess possible suicidal behaviour. The helping relationship should be the interaction between the therapist’s intentions and the client’s reactions (Hill, 2014). According to Gelso (2014), the therapeutic relationship is the core of successful psychotherapy, and the two critical elements of the therapeutic relationship are transference and the real relationship. As a psychodynamic therapist, Paul should encourage this transference intentionally to assist Sophie to get insight into her distress through the therapeutic relationship. Transference is the way the client experiences and perceives the therapist. However, the client is shaped by her psychological structures, including past experiences and involves the displacement and carrying the feelings, attitudes, and behaviours to the therapist deriving from earlier significant relationships (Gelso, 2014).
Sophie displayed sexualised behaviour when she entered the therapy room. Paul did not successfully use transference to develop the conversation around transference behaviour. Instead, he played into it by taking her hand and bowing. During the session, Sophie seemed to “transfer” feelings from people in her life to her therapist Paul by the way she interacted with him. It is interesting to note that Sophie tried to commit suicide using Sy’s bike and taking an overdose of Paul’s medication in his office. Is Sophie trying to say something by using something belonging to Sy and Paul to commit suicide?
Therapeutic Strategies and Skills
Paul is a Psychodynamic therapist however, his methods seem more in line with the Rogerian model. Paul’s strategies include empathic reflections, probing for insights and listening. A positive of the session was that Sophie could speak openly and freely about her problems. Paul was listening to Sophie and displayed nonverbal cues such as nodding and using gestures. He prompted for more information by asking open-ended questions and restated comments. Paul also used alternatives, commenting that Sophie tried to get her mother’s attention by running away from her.
Therapeutic Alliance Ruptures
Safran and Muran (2000) define therapeutic alliance ruptures as impasses or ruptures in the therapeutic alliance. Three roads can lead to an impasse – therapist and client developing a hopeless narrative about presenting difficulties; therapeutic strategy halts; leaving the interaction trapped in a negative pattern. To overcome the impasse, the therapist should become solution-focused and get help during the consultation on developing a new strategy (Safran & Muran, 2000).
Many ruptures occurred during the session as indicated below:
Safran (1993) views ruptures in the therapeutic relationship as the breakdown of the collaboration between therapist and client as indicated below.
Contracting | Privacy and Confidentiality
Problem. Psychologists should be respectful to clients by including them in the decision-making process. Paul called Sophie’s mother behind her back. He did not obtain full and active participation from Sophie on decisions that affected her. Sophie mentioned her mother took her shopping on the weekend because Paul told the mother she was going to “off” herself. Sophie asked Paul why he called her mother. Later on, Sophie expressed anger in an outburst again, telling him how upset she was that he called her mother and told her she was going to kill herself. Paul brushed it off.
Recommendation. During the initial assessment, Paul should have discussed informed consent and the implications thereof. Before involving Sophie’s mother on her suicidal thoughts, Paul should have explained to Sophie that psychologists promote their client’s right to privacy, however, when there is a threat of harm to self and others they are compelled by law to report it. The relationship could repair if the client actively participates in the change process (Horvath, 2009).
Challenges in future sessions. Sophie may become reluctant to share critical information, and risk assessment could become difficult.
Issue. Paul seemed oblivious to the harm caused to Sophie as a result of the ruptures in their relationship. He did not clarify what Sophie could expect from the therapeutic encounter. On a number of occasions, Paul pushed Sophie to go on with her story, even when she was not ready to continue. Paul did not handle the situation competently; he was more interested in what happened next than how the event affected Sophie emotionally.
Recommendation. The therapist’s ideas should not be imposed on the client in therapy (Safran & Muran, 2000). Problems should be addressed within the therapeutic alliance so that the client can reflect on problems. Paul needs to discuss this case in supervision to get guidance on how to deal with the situation.
Issue. When Sophie showed Paul a backflip, she started to walk on the back of the couch; Paul did not know how to deal with the situation. He asked her to stop, but instead of addressing his concerns about her safety, after a perfect landing he said, “That was incredible.”
Recommendation. Paul should discuss potentially harmful behaviours honestly and openly with Sophie and establish boundaries within their relationship. In this way, Sophie could model boundary behaviours from Paul.
Issue. During the session, Sophie also disclosed that Sy had a sexual relationship with her, which Paul seemed to miss.
Recommendation. Paul should have addressed the seriousness of the situation with Sophie and worked towards a plan on how to report the case to the police.
Challenges in future sessions. Paul seems to have difficulty understanding serious issues and how to address it in a lawful way as well as safety practices in his office.
Integrity in Relationships
Issue. Paul was not honest with Sophie. When Sophie confronted Paul about his phone call to her mother, he said: “That’s not what I said.” Later on, Paul admitted to Sophie that he told her mother saying “because I was worried about you.”
Recommendation. A therapist with integrity would have an honest approach. Not dealing with Sophie’s question could hamper trust going forward. Sophie could also view this as an empathic failure and end the relationship. However, the relationship could still repair if they work through the trust issues.
Issue. Sophie does not have clear boundaries; she mentioned: “screwing half the Olympic gymnastics team.” She stayed up all night after a party and then walked to her session for her appointment with Paul. He does not seem to pick up on her cues about her excessive drinking and a boy that she felt was ‘eye candy’. Her lack of boundaries are further apparent when she lies on his couch, and it seemed like she was falling asleep.
Paul’s behaviour did not help. A boundary infringement from Paul was when he sat in front of Sophie, his face only inches away from hers and encouraged her to talk. He then got up and sat very close to Sophie. As a therapist, he should be aware of the boundary breakdown experienced by raped teenagers. He moved next to her and stroked her shoulder, which is highly inappropriate behaviour for a therapist.
Recommendation. Paul should understand the underlying issues of boundaries, perhaps attend a course on how to work with teenage survivors of rape. Paul could have used cognitive processing therapy. CPT treatment includes education, exposure and cognitive techniques. Survivors identify sections of the trauma that they battle to process and then work through stuck points (Galovski, Schuster Wachen, Chard, Manson & Resick, 2015).
Challenges in future sessions. Paul did not address the issue of personal boundaries with Sophie. If Paul does not address or respect boundaries, Sophie could remain vulnerable and victimised.
Responsibility to Society
Paul needs to engage in regular supervision to monitor, assess, and report on his ethical practices to safeguard his clients. An honest exploration of his countertransference would resolve the generational issues he possibly experienced. Furthermore, if Paul does not report Sy to the police, Paul would be doing a disservice to society as a whole, especially vulnerable groups.
Feelings of Dissociation.
Sophie tells Paul about a risky sexual encounter; a gymnast took her to his room, as usual, she felt nothing. On another occasion she said, “everything around me was falling apart, disintegrating, turning to ash right in front of me, … But as soon as I started to fall asleep the pasture would turn to rot, it’s terrible.” Sophie further commented on her eating disorder and how she experienced floating on clouds disassociating from her body when she would not eat when she was younger. She felt that same feeling of when she was on the beam, and enjoyed the sense of disassociation; she pushed until it felt like she didn’t have a body at all.
Effect on Relationship. Paul missed the consistent theme of disassociation.
Recommendation. From a behavioural perspective, survivors of rape can be assisted using CBT (Jaycox, Zoellner & Fao, 2002). Paul can help Sophie to get a new understanding of her thinking patterns that can lead to behavioural change and an understanding of underlying assumptions by directly addressing disassociation. According to the DSM5, disassociation is common in people who experienced PTSD.
Feelings of being objectified
Sophie felt that her mother hated that she was a gymnast. Her mother said:“Your boobs won’t grow, you will hate your body, be deformed”. Her mother also decided on the shoes. “She picked out those Barbie doll shoes” | “Sophie wore those Barbie doll shoes that you bought her…”
Effect on Relationship. Sophie felt objectified by her mother. Paul did not recognise Sophie’s feelings, and he did not explore the Barbie doll comments.
Recommendation. Paul should explore Sophie’s feelings on the shoes and her position as a gymnast. He did not ask her what Barbie doll meant to her. Paul is aware of Sophie’s eating disorder and body image issues. I would recommend DBT strategies which include mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness to help Sophie deal with these issues (Cooper & Parsons, 2010).
The desire to run away
Sophie expressed a desire to run away from her mother to the gymnasium. However, she is unable to get away from her mother.
Effects on Relationship. It is clear that Sophie is not happy at home. Instead of addressing her feelings to run away, Paul tells her the Wizard of Oz story. “…They remind me of, of Dorothy’s shoes. Dorothy discovered that she could go home anytime she wants with or without her shoes.” This was upsetting for Sophie, and she asked him “Why are you infantasizing me?”
Recommendation. Paul did not explore the reasons Sophie wanted to run to the gymnasium. He also did not ask her what she would find there. Exploration (Rogerian approach) could have worked in this instance.
Suicidal thoughts and attempts
Sophie came to therapy to get assessed for suicidal behaviour. The situation that brought her to therapy was when she was on Sy’s bike, and she admitted to Paul that she tried to kill herself. At the end of the session, Sophie went to Paul’s bathroom to vomit, reflected in the mirror, opened the medicine cabinet and removed a bottle of pills and consumed them. Once out of the bathroom, she said she’s going home. Paul told Sophie that they had more time, but she started slurring and fell to the ground.
Effects on the relationship. Sophie attempted suicide using Paul’s medication. This could be due to the culmination of therapeutic ruptures.
Recommendation. Paul did not do a proper risk assessment knowing that Sophie was suicidal. He did not ask her about suicidal plans or how often she had thoughts of killing herself. He should have worked with her on a safety plan. Knowing that he had a suicidal client, he should have removed the medication from his public bathroom.
Therapeutic collaboration stopped when Sophie attempted suicide. Paul did not explore the ruptures that happened during therapy. He did not seem to notice that the therapeutic interaction was blocked. Sophie was unable to cope, and Paul seemed distracted. Behaviours associated with the rupture include Paul’s inability to pick up on Sophie’s cues and the distress she expressed as a result of him speaking to her mother behind her back. When Paul did not know how to respond to issues, he brushed it off or changed the topic. Cozolino (2004) highlights the importance of the psychologist’s intentions to explore the client’s experiences in the moment, which Paul seemed unable to do.
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