Article by Anna Keyter
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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