Modules 5&6

Question 1

What factors should be considered regarding depression as an “epidemic”?

Answer 1

• Professor Wakefield: Increases in depression diagnoses reflect lack of distinguishing clinical from normal sadness (based on context, time)
  
  • Lack of follow up opinion before medicating by GPs
• Mixed evidence for increases in MDD:
  
  • Systematic review Baxter found increases in line with population growth. Did find increases in emotional distress (could be mixed up)
  • Jorm (2017): Rates haven’t dropped despite increases in treatment and awareness. Did find many receiving treatment didn’t meet clinical guidelines.
    
    • ​However, ongoing treatment may be appropriate to prevent relapse
    • DIfferences in measurement styles across 20yrs an issue

Question 2

What did Jorm (2018) find regarding the impact of the Better Access Scheme?

Answer 2

• Better Access Scheme = introduced in late 2006, nationwide roleout (without testing). By 2011, uptake was 3x initial estimates.
• Although use of psychology services role steeply (although starting to level out) levels of psychological distress haven’t changed, nor suicide rates
• Possible reasons:
  
  • Intevention insufficent to produce signficiant change
  • Services may not be going to the highest need groups
  • Quality gap: services may not meet sufficient quality
  • Provision of services may not be impacting on causes of distress such as unemployment, diet, social capital, income
• Limitations: medicare data doesn’t provide full picture (could reflect change in care cost rather than increases)

Question 3

What issues do Mulder et al (2017) identify with stagnant rates of psychological distress?

Answer 3

• In NZ, and other countries, prevalence of psychological distress such as depression and anxiety havent decreased despite increases in services offered.
• Highlights need to reevalute current model of treatment
  
  • Increased medication doesn’t appear to be working
  • Need to shift to preventative model based on modifiable risk factors?
• Factors such as income inequality, prejudice, competitive values
  
  • Low income people have high rates of loneliness and psychological distress

Question 4

What is the role of “big pharma” in the depression epidemic?

Answer 4

• Debate over the role of financially motivated prescriptions
  
  • Bell (2005) suggest 3-fold impact; multinational drug companies, medical practitioners who write prescriptions, the public who turn to medicine for answers
  • Contrast argument; SSRI scripts have plateued
• Prescription Rights: Should psychologists be able to write scripts
  
  • Benefits of integrating medical/psychological intervention
  • Risks of non-medical prescribing

Question 5

What is Thanatology?

Answer 5

• Scientific study of psychology of death, grief and loss. Relatively new field not to be confused with palliative care (focused on pain/management).
• Psychology of grief: not only a response to death but all kinds of loss eg job loss, breakups, amputation, etc
  
  • Grief affects affective, cognitive, physical, behavioural, social, and spiritual functioning
• Thanology examines 4 key characteristics of grief:
  
  • Pervasive: wide ranging effects
  • Dynamic: active process involving emotions/cognition
  • Individual: every experience is different
  • A process: no time limit or static progression

Question 6

What different types of grief are there?

Answer 6

• All four types of grief can be acute or chronic
• Disenfranchised grief: Occurs in response to losses that cannot be openly acknowledged, publicly mourned, or socially supported; four types:
  
  • ​Stigma related to cause of death, stigma related to relationship (eg affair), when relationship not seen as significant (eg pet, early misacarriage) or loss not seen as valid (eg dementia)
• Anticipatory grief: grief experienced in anticipation of eventual loss, for example, grieving whilst loved ones are progressively declining in health, or grieving in anticipation of an upcoming redundancy or divorce.
• Complicated grief: focus for research and practice before DSM-5, a factor in removing the bereavement exclusion criteria. For some individuals the experience of grief is prolonged, debilitating, and results in impairment in daily functioning.
• Developmental, or maturational, grief: grief over life transitions. Some transitions involve relinquishing activities and friends; Empty-nest syndrome and retirement, functional losses associated with ageing.

Question 7

What implications do theories of grief have for practice?

Answer 7

• Original theory:“On Death and Dying” Sucessfully progressing through 5 stages of grief (not currently supported)
  
  • Limited utility since conceptualises client as passive
• Current models describe grief as an active process which takes effort (“grief work”)
  
  • 90% of people don’t require professional help, using their own resources and networks to cope
  • 10% develop impairment and need extra help often social isolation when not feeling supported. Risk factors: attachment style, manner of loss
• Changes in interventions focus: promote attachment to lost person rather than letting go. Restoration oriented (find meaning in loss, reinvest in life)
  
  • Attachment based interventions, schema, CBT etc (sand therapy, play therapy)
  • Reminescence Therapy (go through memories together)

Question 8

What are the causes and effects of disenfranchised grief?

Answer 8

• DG reduces social support and ability of griever to mourn, can also be internalised leading to shame & guilt
  
  • ​Developed through research on death of ex-spouses
• Caused by lack of social recognition of:
  
  • The relationship with the deceased; same sex partners, ex-partners, long lost friends
  • The loss; death of pets, role models, spiritual leaders, non-death loss. Also includes anticipatory grief, or socially stigmatised causes of death.
  • The mourner: People who aren’t considered capable of grieving (too young/too old compared to lost person, disabled)

Question 9

What are the three most common grief trajectories?

Answer 9

• Resilience (45-60%): Short-lived disruptions to overall functioning, tends to resolve within a few months (average 6).
• Recovery (15-25%): Moderate levels of distress following a loss, incl strong feelings of yearning and disruptions to everyday resolves within a yearish.
• Complicated or prolonged grief (10-15%): Considerable, persistent and pervasive grief-related distress, often lasting years.
  
  • Link to sleep disturbances, cardiovascular and cancers, and high-risk behaviours

Question 10

What factors influence grief trajectories?

Answer 10

• Resilience trajectory: younger, increased social support, less loneliness, less dependancy, less anxiety attachment style, greater ability to reflect fondly on loss
• No signficant differences have been found between those in resilience and recovery trajectories
• Compared to resilient, prolonged grief 6x destructive overdependence but 8x higher relationship quality suggesting romanticised view of relationship.
• Greater grief severity only predictor of grief persistence after 6 years
  
  • Grief severity increased for women, loss of child, depression

Question 11

What is positive/successful ageing?

Answer 11

• Positive ageing has two broad goals:
  
  • Develop/implement strategies promoting successful ageing via modifiable factors (eg. illness, optimising capabilities, social interactions, engagement)
  • Explore psychological constructs linked to ageing well.
• What constitutes successful ageing? No clear agreement
  
  • 99% of research on ageing relates to differences between normal and pathological (eg dementia), not best
  • Estimates suggest only 12% of those over 65 meet all criteria for successful ageing, yet some self-report studies had 90% saying they were ageing well
• Factors associated with feelings of sucessful ageing
  
  • Actual age, reduced depression
  • Older people identify “adaptability” AKA resilience

Question 12

What key characteristics are related to positive ageing?

Answer 12

1. Cognitive reserve: Model in which brain plasticity maintains neural processes enhanced through cognitively meaningful and stimulating activities.
2. Mastery: A global sense of control over life and the future. High mastery linked to reduced anxiety, greater problem solving and protection from hardship (financial, health changes).
3. Self-efficacy: High self-efficacy is linked to a higher quality of life, less loneliness, less distress, better cognitive function.
4. Wisdom: Thought to consist of three domains. Cognitive (expert knowledge, reasoning) Affective (postive emotions, emotional regulation) and Reflective (accepting alternative views, perspectives).
5. Resilience: The ability to maintain subjective wellbeing despite experiencing challenges.
6. Spirituality: Due to the meaning religiosity/spirituality can contribute to life, but also linked to response to illness, greater resilience, and improved health behaviours. Also Self-reflection and the search for existential meaning
7. Purposeful engagement/sense of purpose: Activities that maintain social roles, align with values, meaningful to the individual. Ie. setting/fulfilling objectives, ongoing learning, and viewing life as having potential.

Question 13

What is the evidence for positive ageing interventions?

Answer 13

• Supporting evidence: Strongest evidence is for diet and exercise interventions, however large variation in styles impairs meta-analysis.
  
  • The most effective interventions; Adopted a community development approach;Had the ability to be adapted to fit a specific local area; and focused on productive engagement
• Critics argue that positive psychology is bad science, based on abstract, poorly defined and tested ideas.
  
  • Eg altruism
  • issues with terminology; does getting sick mean you have “failed” if the opposite is success?
  • Implications that unsuccessful ageing is a personal failure.

Question 14

What changing themes in models of grief are outlined by Hall (2014)?

Answer 14

• Rejection of “stages” of grief: Early grief models focused on phases and stages which need to be worked through.
  
  • Freud: 3 stages: letting go, radjusting to new circumstances, forging new bonds
  • Kubler Ross: 5 stages of grief.
• Multiple trajectories of grief: Bonnano identified 5 common trajectories of grief with varying levels of resilience and depression
  
  • ​Duel Process Model: grief is an oscillation between two modes - loss orientation and restoration orientation
  • Task-Based model: Active model where people have 4 tasks, also 7 factors which influence trajectories
• Continuing Bonds: Move away from “letting go/moving on” models towards acknowledgement of maintaining a connection to the deceased
• Reconstruction of meaning: postmodern socialist construction approaches focus on making sense of the loss and finding new meaning.
  
  • ​Two concepts: Making sense of the loss, and finding benefits (eg growth)
  • Failure to find meaning is linked to hightened complications

Question 15

What does Hall (2014) indentify regarding complications of grief?

Answer 15

• Complicated grief disorder: 10-15% of people experience intense/chronic grief for months or years.
  
  • Often result of unexpected, untimely deaths (violent, accident, death of child)
  • DSM-5; although not yet clear enough for inclusion, identified as of interest, led to grief-exclusion of MDD
• Grief interventions:
  
  • Evidence shows intervention is only effective for prolonged or complicated grief
  • Antidepressants aren’t effective
  • Interventions need to flexible due to highly individual process of grieving

Question 16

What does McNutt (2013) highlight regarding disenfranchised grief in LGBTIQ?

Answer 16

• LGBT widows/widowers often experience increased social exlusion in terms of:
  
  • Exclusion from funeral plans by deceased’s family, Lack of legal recognition, Lack of relevant social support structures, AIDS stereotypes for gay men
  • Anticipated grief appears stronger in LGBT couples
  • Componding issues for aged care
• Implications for counselling: Consider own biases and assumptions
  
  • Remain aware of possible discrimination during illness
  • Use affirmative stance; consider narrative therapy, CBT, address internalised stigma
  • Consider unique stories, compounding pressures

Question 17

What limitations does McNutt identify in LGBT grief research?

Answer 17

• Limited current research on gay deaths not related to AIDs
• Need for greater focus on older LG people
• Incorporation of LGBT people into other grief studies
• Role of compounding factors and identities

Question 18

How does positive psychology meld with healthy ageing according to Stirling?

Answer 18

• Changing views of old age toward flourishing: The clearest connections between happiness and its possible causes are seen in the elderly
• Emotional regulation appears to improve in older age
  
  • Increased focus on positive, cognitive control over re-appraisal of past choices,
  • Socio-emotional selective theory; awareness of finite time causes changing motivations immediate, positive valuable goals.
• “Gerotranscendence” = increased life satisfaction, reduced self-occupation, heightened affinity to others across 3 dimensions:
  
  • Cosmic dimension (changing sense of time as wholistic)
  • Dimension of self (looking outward)
  • Social dimension (fewer high value relationships)
• Environments for thriving arise when a) social roles involve wellbeing b) drawing strength and resilience from older community members c) include disability as a normalised part of life.

Question 19

What is the role of positive psychology in chronic illness management?

Answer 19

• Keyes model of mental health in ageing: Two variables (psychological wellbeing and chronic illness symptoms) result in four types of coping skills
  
  • Adapting (high/high) flourishing (highP/lowCI), floundering (lowPW/HighCI) Languishing (Low/low)
• Factors that influence coping with chronic illness:
  
  • Resilience: Capacity for adaptation. Fostered through secure attachments, self-esteem, a sense of agency
  • Optimism and positive expectancy; Increased flexible coping strategies, sense of control, societal level expectations re ageing
  • Self-efficacy: Use of goal setting, thoughts of self-agency, viewing limitations as opportunities

Question 20

What is terrorism?

Answer 20

• Combs: No universally accepted definition between academic /political/ general contexts. However, four common features agreed apon
  
  • Targeting civilians
  • Driven by political/social motives
  • Used to create fear
  • Involves acts of violence
• Categories of terrorist acts (Combs):
  
  • Mass terror: committed by political leaders to general population (e.g., Stalin)
  • Random terror: committed by individuals or groups, targeted at civilians (e.g., 9/11)
  • Focused random terror: Similar methods as random, but in areas with large numbers of the opposition (e.g., Israeli-Palestine conflicts).
  • Dynastic terror: assassinations targeting a ruling elite or state leader (e.g., the assassination of Benazir Bhutto).
  • Lone wolf terror: individuals acting alone, targeting governments or civilians

Question 21

What are some key challenges in studying terrorism?

Answer 21

• Lack of agreed definition
• Overreliance on secondary sources; newspaper reporting
  
  • Including secondary reporting of manifestos
  • Subject to bias, inaccuracy, underreporting
• Difficulty accessing primary sources/direct interviews
  
  • With purpetrators or family

Question 22

What did Vergani et al (2019) find re Terror Management Theory?

Answer 22

• TMT theory = cultural worldview and self-esteem are intertwined and buffer existential anxiety. Increased mortality salience (MS) prompts extremism to combat increased fear.
  
  • Limits of previous research linking MS to radicalisation
    
    • inconsistent MS measurement, A-priori hypotheses, researcher bias,
• Experiments: 3 studies with MS manipulation (AUS, AUS primed with antiviolence, young jewish students)
  
  • MS did not increase support for violence in any study
  • MS did increase support for conservative religious policies, divine power in study 1 (not in study 2 after antiviolence prime)
• Limitations: extremist values may be too generic, too disconnected from experiences of non-extreme samples

Question 23

What did Das et al find supporting the Terror Management Theory of radicalisation?

Answer 23

• Das et al examined the pathway of death-related thoughts in the relationship between mortality salience and extremist views. Examines 3 assumptions of TMT:
  
  • Pivotal role of death-related thoughts in predicting prejudice
  • Self-esteem reduces effects of MS
  • MS will increase prejudice against any outgroup
• Experiments: 3 studies tested exposure to terror news or control.
  
  • All 3 primes increased death-related thoughts, which in turn influenced prejudice.
  • Study 1: death of artist in terror half way though created ceiling effect. Prejudice was only seen after death.
  • Study 2: prejudice rates higher with low self-esteem
  • Study 3: terror news increased prejudice against arab for whites, against whites for arab audiences
• Limitations: unclear mechanisms for arab prejudice (anticipated stimga?)

Question 24

What is Benedek, Ursano and Holloways 4-Phase model of response to terrorism?

Answer 24

1. Immediate Aftermath: Strong emotional reactions incl numbness, disbelief, fear and confusion
2. 1 week to several months: Involves active efforts to adapt to the new environment. May include:
   
   • Intrusive and hyperarousal symptoms
   • Somatic symptoms such as headaches, dizziness, and nausea.
   • Anger, irritability and social withdrawal.
3. Several Months: Emergence of disappointment and resentment as it becomes evident that aid and restoration is unlikely to lead to complete return to pre-attack status.
4. Months to years: A reconstruction phase typified by physical and emotional re-building, resumption of old roles, re-establishing social connections.

Question 25

What psychological disturbances are common following terror attacks?

Answer 25

• Anxiety: 90% of Aus teenagers sampled reported anxiety re war and terrorism (reduced through talking about fears). Community samples report 4 main anxiety themes:
  
  • Fears of physical harm
  • Political fear ie. anxiety about social consequences that communal fear generates through demonising one element
  • Fear of losing civil liberties
  • Insecurity brought about by a feeling of reduced safety
• Depression: some evidence of increased depression following events (incl pos association between depressive symptoms and feeling threatened).
  
  • ​Risk increased when female, low social support, comorbid stressors and disorders
• Substance Use: Alcohol, cigarettes, cannabis, increase among victims and general population following terror attacks. Meta-analysis​ showed 7-17% increases.
• PTSD: Rates of PTSD vary (12-20% 9/11, 3% Madrid, 9% Isrealis). Risk factors include being direct victim (30-40%), previous stress, female, Low SES
• Positive effects - Resilience: 30-65% of New Yorkers demonstrated resilience in 6 months following 9/11 (lower rates corresponding to higher exposure). Limited studies.

Question 26

What are some psychological perspectives on terrorism treatment?

Answer 26

• Three-phase intervention strategy; structure for assessment and intervention:
  
  • Normalisation of symptoms in first few days
  • Screening for high risk individuals
  • Referral of symptomatic individuals to clinical services
• Conservation of Resources Theory: psychological stress is the result of loss of resources, the threat of lost resources, lack of gained resources that were expected. Resilient individuals have the capacity to aquire/maintain resources to buffer the loss.
  
  • ​perceived loss of resources linked to increased symptoms
• CBT: Argues that psychopathology results because terrorism challenges our cognitions, resulting in cognitive distortions that, in turn, impact on emotions and behaviours.
  
  • Catastrophising: expecting the worst
  • Helplessness: a sense of being powerless
  • Rumination: process of repeatedly thinking about a problem or event. Not a cognitive distortion itself, but enhances distotions them

Question 27

What challenges does Maier identify when working with refugees?

Answer 27

1. Severity of Trauma, Shattered Assumptions, Loss of Self-Sameness: Trauma often surpasses what is seen in civil clients. Average 4 exposures.
   
   • More than classic PTSD symptoms, inc paralysing shame, anger
   • Shattered trust in humanity, loss of religious faith
   • Isolation from inability to share experience
2. Physical Disabilities and Complaints: Torture victims also have complex relationships with their bodies; simultaneously representing weakness and strength.
3. Insecure Residency Permit Status: Instability, fear of deportation etc. Sometimes mental health is the only reason they are granted temp visas.
4. Cultural and Social Uprooting: Lack of support structures, language barriers, impacts of having a translator, etc.
5. Survivor’s Guilt, Perpetrator’s Guilt, Moral Injury: Feelings of shame and guilt arise from feeling they survived at anothers expense. Often refugees have done bad things to survive.
   
   • ​Moral conflict = inner conflict of actions and ethical beliefs

Question 28

What five adjustments to CBT are suggested by Fortuna when working with refugees?

Answer 28

1. Extending the psycho-educational element of therapy. Highly likely this is clients first experience with mental health services. Discuss what help can be provided and the emotional and physical impact of trauma.
   
   • Allows for a sharing of information
2. Explore the symptoms of PTSD in the client’s own words. Position the refugee as the expert of their own experience and show an openness for the therapist to accept their culture and their views.
3. Explore the impact of trauma on role functioning. Understanding valued roles and how they have been disrupted can be crucial.
4. Involve the client in therapeutic goal setting Therapist goals such as independence, individual responsibility and autonomy may not be relevant in the cultural context of the refugee client. Incongruent goals between therapist and client is likely to contribute to client drop out of therapy.
5. Obtain supervision. Cultural issues need to be explicitly explored and discussed. Consideration of power differentials and trust need to be examined.

Question 29

What are some important elements of cultural competence when working with refugees?

Answer 29

• Understanding of symptoms and causes of mental illness vary across cultures
  
  • PTSD especially presents as different somatic symptoms (eg night sweats in cambodia)
  • How to define abnormal behaviours eg cross cultural scale validation
  • Risk of stereotyping; eg assigning cultural factors to treatment resistence rather than cost/accessibility.
• Klienman Explanatory Model; ask the client in their own words what the problem is, what they believe to cause it etc.
  
  • “Cultural idioms of distress” rather than culture bound syndromes.
  • Bhurma doesn’t have a word for depression
• Cultural stigma; mental illnesses carry different stigmas in different cultures based on labelling

Question 30

What are the benefits of alternative approaches to treating refugee mental health?

Answer 30

• Examples of alternative treatments: use of creative outlets
  
  • Art therapy, writing, speaking, dance and movement
• Benefits of alternative therapies
  
  • Western therapy modesl are often confusing and unsettling for refugees - many creative outlets are universal
  • Creative outlets allow a story to be told, processed with cognition, emotions and physical work
  • Creativity invites growth, expansion and connection
  • Can incorporate breathing, mindfulness etc
  • Allows an outlet for both opening up and expressing emotions

Question 31

What is postive education and its benefits?

Answer 31

• Positive education = umbrella term for application of positive psychology to school environment stemming from Steligman’s work
  
  • Prevention of mental illness in adolescents, creating well rounded adults
• Empirically supported benefits of positive education:
  
  • Individual growth: promotes personality strengths and long term behaviours
  • Wellbeing: introduction of PP classes in schools increased knowledge of factors and pratical skills to increase thriving and flourishing
  • Decreased depression: includes elements known to reduce depression such as positive visualisation
  • Achievement: happy students are higher achievers with greater engagement
  • Benefits to teachers: benefits to school culture and easier to engage students with better self mastery skills

Question 32

What are some examples of Positive Education programs?

Answer 32

• Penn Resiliency Program (PRP): Aim increase student ability to deal with everyday stressors through cognitive flexibility, problem solving, assertiveness, relaxation.
  
  • Long term reduction of helplessness, behavioural problems and depression/anxiety symptoms.
• Strath Haven Positive Psychology Curriculum: Year 9 students completed exercises incl “writing down 3 good things that happened today” and identifying/applying signature strengths
  
  • Increased learning and engagement, and social skills
• Seligmans PERMA model: 5 pillars of wellbeing:
  
  • Positive Emotions: eg feeling joy, gratitude, interest, hope.
  • Engagement: Absorption in activities that utilise and challenge skills
  • Relationships: Having positive relationships.
  • Meaning: Belonging to and serving something you believe is bigger than yourself.
  • Accomplishment: Pursuing success, winning achievement and mastery.

Question 33

What does Green (2011) outline regarding positive education programs in Australia?

Answer 33

• Current programs in Aus
  
  • Geelong Grammar School; integration of positive education classes in years 7 and 10 (fortnightly class), co-curicular etc
    
    • not scientifically investigated
  • Knox Grammar School: 3 yr strategic positive education intervention followed by UOW
  • Grays Point Public School; Multi-layer intervention, teacher training, grandparents day, classwork etc
• Positive Education vs Coaching
  
  • In addition to positive psych interventions (PPIs), there is increased use of evidence based coaching to increase resilience, wellbeing etc.
  • These interventions currently operate in isolation - may benefit from future integration.
    
    • Benefits of training can be transfered to PPIs

Question 34

How is concept creep demonstrated abuse, bullying and prejudice?

Answer 34

• Abuse: Traditionally refered to physical or sexual abuse.
  
  • Horizontal (qualitative) creep: psychological, emotional abuse, neglect
  • Vertical (quantitative) creep: definition of emotional abuse and neglect is widening, often overinclusive
• Bullying: aggressive, repeated, intentional acts in context of a power imbalance, almost always between children
  
  • Horizontal creep: Cyberbullying, workplace bullying, indirect acts such as ignoring, excluding
  • Vertical creep: Intention, repetition and power imbalance less central to definition now.
• Prejudice: Hostile attitude to outgroup
  
  • Horizontal creep: modern, unconscious racism, denial of prejudice and non-hostile stereotypes, implicit
  • Vertical creep: microaggressions, exclusion

Question 35

How is concept creep evident in trauma, mental illness, and addiction?

Answer 35

• Trauma: originally an external damage to the body with psychological ramifications
  
  • Horizontal creep: Primarily damage to psychological state not body (eg PTSD)
  • Vertical creep: reducing severity requirements for initial trauma based on individual factors
• Mental Illness: DSM-1 had 106, DSM4-300
  
  • Horizontal creep: evident across DSM versions, some new illnesses were previously personal flaws eg personality disorders, childhood
  • Vertical creep: loosening of threshold criteria towards spectrums ie ASD, melancolia (immobilised) vs depression
• Addiction: originally a physiological dependence on a substance
  
  • Horizontal creep: inclusion of behaviour and process addictions (gambling, internet, porn)
  • Vertical creep: “soft” addictions with external costs without required proof of withdrawal, tolerance, physiological effect