A Resource Book for Good Mental Health

Taking Care

of Yourself and

Your Family

A Resource Book for Good Mental Health Supported by beyondblue: the national depression initiative

John Ashfield

You can order more copies of this book by visiting the beyondblue website http://www.beyondblue.org.au under Get Information

                

Parts of this book may be copied for personal or professional use. Any other use requires that the usual provisions of copyright, such as permission of the publisher and proper acknowledgement of source, author and publisher, be observed.

Please note: The information and self-help resources in this book are not intended as a substitute for mental health assessment, medical or psychiatric consultation, assessment or treatment.

Published for beyondblue: the national depression initiative by Peacock Publications
38 Sydenham Road, Norwood, South Australia 5067 Copyright © Mid North Health, 2004

11th edition published March, 2010 Reprinted July, 2010
Reprinted October, 2010
Reprinted March, 2011

National Library of Australia Card Number & ISBN 978-1-921601-09-5 Printed by Peacock Publications, Adelaide

ii

Acknowledgements

Preparation, Layout and Design

Ruth Loechel (editions 1-9)
beyondblue: the national depression initiative (editions 10, 11)

Editing

Cynthia Collins (editions 1-10)
beyondblue: the national depression initiative and SA Country Health (edition 11)

Professional Advisory Reference Group

Ian Reid
Men’s Health Consultant

Shane Montgomerie
Drought Counsellor, Mid North Rural Counselling and Information Service

Mark Cuthbertson
Rural Counsellor,The Flinders and Pastoral Rural Counselling and Information Service

Jim Herbert
Youth Development Officer, Regional Health Services Program

Jim Cawthorne
Project Manager, Rural Solutions SA

Marcus Connelly
Mental Health Social Worker, Port Pirie Regional Health Service

Community Advisory Reference Group

Booleroo Centre

Brenton & Melissa Koch Mark Reichstein Graham Zanker

Peterborough

Peter & Jan Malycha

Orroroo

Peter Barrie
Jim & Gaye Kuerschner

Jamestown

Mary & Dennis Clark

beyondblue and SA Country Health wish to thank contributors to the 11th edition: Australian Centre for Posttraumatic Mental Health and the Australian Drug Foundation.

iii

iv

Contents

Foreword from SA Government ……………………… vi Foreword by The Hon. Jeff Kennett …………………. viii Introduction…………………………………………………… ix Depression …………………………………………………… 1 Anxiety ………………………………………………………… 41 Disturbing Thoughts……………………………………. 87 Recovery from Trauma ……………………………….. 103 Insomnia…………………………………………………….. 119 Con ict ………………………………………………………. 149 Anger …………………………………………………………. 159 Stress …………………………………………………………. 177 Relationship Violence ………………………………….. 217 Alcohol ………………………………………………………. 225 Substances and Mental Health ……………………. 253 Grief…………………………………………………………… 267 Key Services and Resources ………………………… 301

Perinatal depression and anxiety ……….. 315 Chronic illness and mental health………. 316 Aboriginal and Torres Strait Islanders … 318 Young people…………………………………….. 319

Sources used in the preparation of this book …… 320

You can order more copies of this book by visiting the beyondblue website http://www.beyondblue.org.au under Get Information or by calling the beyondblue info line on 1300 22 4636.

   

v

Foreword

As Australian rural communities and families endeavour to cope with the impact of the recent debilitating drought, it is very important to have good, practical reference material that helps by giving tips on maintaining and protecting their health and well-being.

Australians are acknowledged as having great resilience in times of difficulty and uncertainty, but living and working on the land in the face of extended dryness, challenges even the most resilient.

More recently, for those who have experienced the impact of extensive flooding in Queensland and New South Wales, and the devastating fires in Victoria, the need for helpful information is essential as they face the process of rebuilding their properties and indeed, their lives.

Although disasters such as flood, fire and drought are an integral part of the Australian way of life, the physical and psychological burden that these cataclysmic events place on those affected is immense.

The South Australian Government is working with rural communities to build local capacity and to sustain personal resilience in these challenging times. Providing ways to help people care for their mental well-being is crucial. It is equally important that we also care for our families, neighbours and communities by recognising emerging signs of problems that may require professional support. Early assistance and intervention can help prevent unnecessary distress.

Taking Care of Yourself andYour Family was written in close consultation with people living and working in rural communities, some of whom can readily identify with the effects that drought

vi

or other events can have.The book provides valuable advice and reflects the most current mental health issues that rural health services and rural people themselves have identified.

The book is one of a range of South Australian Government mental health initiatives which aim to provide people with practical and relevant information and self-help resources.

The 11th edition of Taking Care of Yourself andYour Family is
an important collaboration between Country Health SA and beyondblue: the national depression initiative.The content and the helpline information have been revised to make it nationally relevant, drawing on beyondblue’s experience in tackling depression and anxiety across Australia.

Taking Care of Yourself andYour Family is a valuable resource for the Australian community, to maintain good mental health and well-being. It is important to remember that if you don’t take care of yourself and your own well-being, it becomes harder to take care of your family and those you cherish.

I commend this book to you.

The Hon. John Hill MP
SA Minister for Mental Health and Substance Abuse

vii

Foreword

We know Australians are becoming more aware that depression is not a weakness, but a condition that needs treatment.

We also know that Australian men aren’t good at looking after themselves. So, I’d like to encourage men to read this book and then, if need be, talk to their doctor about their mental health as well as their physical health.

If you broke your arm or gashed your leg, you wouldn’t expect that it would get better all by itself. Depression is the same – it won’t go away if you ignore it – in fact it can get worse and untreated depression can not only be a risk factor for suicide, but can make you susceptible to physical illness as well.

beyondblue, with the support of funds raised by The Movember Foundation is making this book – Taking Care of Yourself andYour Family – available free to people throughout Australia.You’ll nd helpful information and self-care strategies that may assist you to get through the tough times and nd the right help.

To order additional copies of the book or for more information on depression, anxiety and related disorders, and where to get help visit http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636 (local call).

The Hon. Jeff Kennett AC
Chairman
beyondblue: the national depression initiative

               

viii

Introduction

Initially, this book was compiled for use by people in rural and remote areas of Australia who have little or no useful access to the kinds of counselling and psychotherapy support that people in urban centres can generally take for granted.While the book targets rural and remote Australians, it’s also helpful for other people as well. Some people may be unable to access local mental health services due to the location and cost of these services, or due to work commitments and a lack of time.This book provides useful information and practical strategies to help promote good mental health for everyone.

Given the vast area of rural Australia, and the limited resources of community mental health services, it has proven difficult to focus effectively on measures of preventative mental health, as well as responding to the demands of mental health crises and people with longstanding mental disorders.

General medical practitioners are often frustrated in responding to the mental health needs of their patients, because they sometimes have little choice but to prescribe medication to control symptoms for which they would prefer to recommend psychological therapy, if it were available. Likewise, where a combination of medication and psychological therapy is needed, the former is often all that can be provided.

This book is not intended as a substitute for psychological therapy (or psychotherapy), or formal mental health assessment. But it does aim to provide an additional resource for prevention, early detection, intervention, self-help, and education in relation to some common mental health issues and mental disorders. Its design takes account of the known resourcefulness, self-reliance and resilience of many people who live in our often harsh and isolating rural and remote areas.

ix

The topics covered in the book were chosen because they have been found to be the most recurrent themes encountered by doctors and other human service providers.

The intended uses of the book include:

• A source of basic information about a range of mental health and related issues.

• A guide for helping others, or prompting them to seek assistance, in the event of a mental health issue.

• A resource of strategies and self-help therapies that have been adapted from some widely used and documented standard psychological therapies.

• A resource that can be photocopied and self-help therapies that doctors can use as handouts for their patients.

• A resource for use in basic community mental health education.

• A resource for health and human service workers.
The content of the book is organised so that readers are not required to read any more information than they need or interests them. Problem identi cation checklists are placed at the beginning of relevant sections so that, even if no other part of the section is read, the checklist may be.
A number of the self-help resources (such as Structured Problem-Solving) are provided in more than one section, to avoid readers having to refer to another part of the book in addition to the section they are reading.
Language, practical examples, and some of the diagrams used have been selected in order to be gender inclusive, or ‘user friendly’ for men as well as women.
It is hoped that the information and resources of this book
will not only stimulate interest and concern about mental health issues, but will contribute something to the capacity of Australians to take care of their own and each other’s mental health – often despite limited professional services and support.
x

Depression

1

For more information about depression, visit the beyondblue website at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

    

DEPRESSIon CHECK

              

For more than TWo WEEKS have you: Tick if Yes 1. Felt sad, down or miserable most of the time? m 2. Lost interest or pleasure in most of your usual activities? m

If you answered ‘YES’ to either of these questions, complete the symptom checklist below. If you did not answer ‘YES’ to either of these questions, it is unlikely that you have a depressive illness.

3. Lost or gained a lot of weight? OR Had a decrease or increase in appetite? m

4. Sleep disturbance? m

5. Felt slowed down, restless or excessively busy? m

6. Felt tired or had no energy? m

7. Felt worthless? OR Felt excessively guilty? OR Felt guilt
about things you should not have been feeling guilty about? m

8. Had poor concentration? OR Had dif culties thinking? OR Were very indecisive?

9. Had recurrent thoughts of death?

Add up the number of ticks for your total score:

What does your score mean?

m m

_____

(assuming you answered ‘YES’ to question 1 and/or question 2.) 4 or less: Unlikely to have a depressive illness
5 or more: Likely to have a depressive illness

If you have some of these symptoms and they are affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor

 

2

DEPRESSION

Thoughts about suicide or self harm are serious. If you are having these thoughts –

.TAKE URGEnT ACTIon.

Arrange to speak to a doctor OR

Phone a 24-HoUR MEnTAL HEALTH EMERGEnCY LInE

national

Lifeline: 13 11 14
Suicide Call Back Service: 1300 659 467

State and Territory
ACT:
Crisis Assessment and Treatment Team: 1800 629 354 nSW: Salvo Suicide Prevention & Crisis Line: Metro

02 9331 2000
Salvo Suicide Prevention & Crisis Line: Rural 1300 363 622 Suicide Prevention and Support: 1300 133 911

nT: Mental Health on Call Team:Top End (08) 8999 4988 Mental Health on Call Team: Central Australia
(08) 8951 7777

QLD: Salvo Crisis Counselling Service: Metro 07 3831 9016 Salvo Crisis Counselling Service: Rural 1300 363 622

SA: Mental Health Assessment and Crisis Intervention Service: 13 14 65

TAS: Mental Health Services Helpline: 1800 332 388 VIC: Mental Health Advice Line: 1300 280 737

SuicideLine: 1300 651 251
WA: Mental Health Emergency Response Line: Metro

1300 555 788
Rural Link: Rural 1800 552 002 Samaritans Crisis Line: 1800 198 313

nATIonAL HELP/InFoRMATIon LInES

beyondblue info line: 1300 22 4636
Lifeline: 13 11 14
MensLine Australia: 1300 78 9978
Kids Helpline: 1800 55 1800
Australian Psychological Society Referral Line: 1800 333 497 SANE Australia: 1800 18 7263

 

Relationships Australia: 1300 364 277 Carers Australia: 1800 242 636

3

DEPRESSION

  

About Depression

Depression is more than just a low mood – it’s a serious illness. While we all feel sad, moody or low from time to time, some people experience these feelings intensely, for long periods of time and often without reason. People with depression nd it hard to function every day and may be reluctant to participate in activities they once enjoyed.

Depression is one of the most common mental health problems. Over one million people in Australia experience depression each year.

Everyone has a bad day now and then. There is no shortage
of life events that can leave us feeling distressed, disappointed or just plain lousy. The problem is when these kinds of feelings persist; when long-lasting changes in mood, feelings and behaviours develop into depression. And yet, on occasions, depression just seems to come out of nowhere, at a time when everything appears to be ne.

Many factors may contribute to depression including:

• a family history of depression

• hormonal changes (in women and men)

• emotional stress (e.g. bereavement, job loss, relationship breakdown)

• medicines (e.g. some cancer and heart medicines)

• medical conditions – such as thyroid and other hormone problems, or battling a chronic or terminal illness (see page 316 for more information on co-morbid chronic illness and depression).

• personality – the type of person you are and how you respond to life events
4

DEPRESSION

• social support – whether you have suf cient supportive people around you. People isolated on farms or station properties may lack important social support.

• life changes – major life events such as the birth of a baby may increase the risk of developing depression. See page 315 for more information on perinatal depression and anxiety.
What if depression is left untreated?
Getting the right treatment early is crucial to a person’s recovery from depression. Left untreated, an episode of major depression may last from six to 12 months or longer. Half the people who recover from an untreated episode of depression will slip back into their former state of depression within two years of their rst episode.
Depression is a serious disorder. Even ‘minor’ depression can become very disruptive to people’s lives – more so than many physical disorders. However, when depression is properly treated, most people can expect a full recovery.
What are the treatments for depression?
Different types of depression require different types of treatment.This may include physical exercise for preventing
and treating mild depression, through to psychological and drug treatments for more severe levels of depression.The major types of treatment for depression include psychological treatments, antidepressant medication, and self-help strategies.
For more information on treatments see beyondblue Fact sheets 4, 10, 11 and 24 and A Guide to What Works for Depression – a comprehensive review of all known treatments for depression, including medical, psychological, complementary and lifestyle, available at http://www.beyondblue.org.au or by calling the beyondblue info line 1300 22 4636.

  

5

DEPRESSION

IMPoRTAnT

• Self-help measures are no substitute for medication if medication is needed.

• Thoughts about self-harm or suicide are serious. Speak to a doctor or call a 24 hour mental health crisis line immediately.

DEPRESSION

Psychological treatments

Psychological treatments deal with problems that particularly affect people with depression.These treatments help people to change negative patterns of thinking and/or sort out relationship dif culties.

Psychological treatments can help to:

• change negative thoughts and feelings

• encourage the person to get involved in activities

• speed the person’s recovery

• prevent depression from recurring

• identify ways to manage the illness and stay well.
Psychological treatments include Cognitive Behaviour Therapy (CBT), which is one of the most researched psychological therapies and has a lot of evidence to support
its effectiveness in treating people for depression and anxiety disorders. It teaches people to think realistically about common dif culties, helping them to change their thought patterns and the way they react to certain situations. Behavioural therapy approaches have been shown to be very helpful for many anxiety disorders.
Interpersonal Therapy (IPT) is another psychological treatment which has been researched and found to be effective for treatment of depression. It helps people nd new ways to get along with others and to resolve losses, changes and con ict in relationships.
6

Psychological treatments can be provided by GPs, psychologists, social workers, occupational therapists in mental health, and psychiatrists. In some regions, particularly in rural and remote Australia, this type of therapy is not always available. Online options such as MoodGym (www.moodgym.anu.edu.au) are good alternatives if people aren’t able to access a mental health professional.

The self-help strategies provided in this chapter are based on psychological treatments.

If a person is only mildly or moderately depressed, psychological treatment alone may be effective. However, if depression is severe or persists, medication may also be needed.

MEDICARE REBATES

A rebate can be claimed through Medicare for ‘Psychological Therapy’ or ‘Focused Psychological Strategies’ when a GP, psychiatrist or paediatrician refers a person to a clinical psychologist, registered psychologist, social worker or occupational therapist in mental health.A rebate can

be claimed for part of the cost of up to 12 individual consultations (more in exceptional circumstances) and
12 group sessions in a calendar year. If the mental health practitioner bulk-bills, there will be no upfront charge and therefore no reason to claim a rebate.

For more details, ask your referring medical practitioner
or see beyondblue Fact sheet 24 – Help for depression, anxiety and related diorders under Medicare.
For a list of health professionals with expertise in treating depression, go to the beyondblue website: http://www.beyondblue. org.au and click on Find a Doctor or other Mental Health Practitioner or call the beyondblue info line on 1300 22 4636.

   

7

DEPRESSION

 

Antidepressant medication

There is a great deal of misinformation about antidepressant medication.

Antidepressant medications:

• ARE NOT addictive

• DO NOT change your personality

• DO NOT make people more dangerous
Antidepressant medication can play a role when people become severely depressed or when other treatments are ineffective in the treatment of depression. Deciding which antidepressants are best for a person can be complex.There is a range of factors that should be discussed with a doctor before starting antidepressants.
It’s important that any current medication or over-the-counter medications including herbal or natural remedies are reviewed by a medical practitioner before a person starts taking antidepressants.
Antidepressant medication can take 14 to 21 days before beginning to work effectively.The prescribing health professional should discuss differences in effects and possible side-effects of medications. Stopping medication should only be done gradually, on a doctor’s recommendation and under supervision.
Most people taking medication will also bene t from psychological therapies, which will reduce the likelihood of relapse after the person has stopped taking the medication.
The Therapeutic Goods Administration (Australia’s regulatory agency for medical drugs) and manufacturers of antidepressants do not recommend antidepressant use for treating depression in young people under the age of 18. For more information see beyondblue Fact sheet 11 – Antidepressant medication.

DEPRESSION

8

Self-help strategies

Any doctor can prescribe antidepressant medication – however, it’s important that people try to help themselves to recover and work towards preventing a relapse – with or without medication.

Self-help includes:

• managing thoughts and self-talk

• structured problem-solving

• activity planning and exercise

• reducing alcohol consumption to a moderate level

• managing stress

• restoring a pattern of normal sleep.
The activities in the following pages provide a range of different self-help strategies for managing depression.
What can I do to help someone who is depressed?
People who are depressed are not always easy to help because often, they are disinterested, lack energy and motivation,
can be irritable, and may not see the point of doing anything. Some people are not used to talking much – especially about themselves, so even getting a conversation going can be dif cult.

 

For more information, see A Guide to What Works for Depression at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

9

DEPRESSION

 

Useful tips for helping someone who may be depressed

• Think about the best way to approach the person – given what you know about his/her personality and temperament.

• Discreetly let the person know you have noticed a change in his/her behaviour. Indicate that you are seriously concerned.

• Talk openly about depression and suggest the person visits a doctor, or speaks to a health professional recommended by a doctor.

• If appropriate help the person to make the appointment; perhaps consider going with him/her – and follow up after the appointment.

• If you think the person won’t listen to you, consider: Who does this person usually con de in, feel comfortable with, and/or trust? Maybe that person could make the approach and encourage him/her to seek assistance?

• Provide the person with information about depression; give him/her a copy of this book or this section on depression – or refer the person to http://www.beyondblue.org.au

• Try to nd ways of reducing the person’s isolation:
– Make an extra effort to stay in touch, preferably in person. – Encourage other close friends and family to do the same.

• Encourage the person to excercise, eat well and become involved in social activities.
It’s unhelpful to:

• Pressure people with depression to ‘snap out of it’, ‘get their act together’ or ‘cheer up’

• Stay away or avoid them

• Tell them they just need to stay busy or get out more

• Pressure them to party more, or to wipe out how they’re feeling with drugs or alcohol

• Assume the problem will just go away. 10

DEPRESSION

Ø Thoughts about self-harm or suicide are serious. Be as determined and resourceful as you can in nding a way to get a person having these thoughts to speak to a doctor or appropriate health professional.

..HoW To TALK To SoMEonE ABoUT DEPRESSIon..

It’s not always easy to know how to help someone who may be experiencing depression. It can be hard to know what to say or do. Here are some tips.

• Talk to the person about how he/she is feeling.

• Listen to what the person is saying – sometimes, when people want to talk, they’re not always seeking advice, but just need to talk about their concerns. Make it clear the person has your full attention and you are listening properly. You may like to save any suggestions for a later discussion.

• Maintain eye contact and sit in a relaxed position – positive body language will help you both feel more comfortable.

• Use open-ended questions such as ‘So tell me about…?’, which require more than a ‘yes’ or ‘no’ answer. This is often a good way of starting a conversation.

• If your conversation becomes dif cult or the person you’re talking to gets angry: stay calm; be rm, fair and consistent; admit if you are wrong and don’t lose control.

• Often, just spending time with the person lets him/her know you care and can help you understand what he/she is going through.

• Encourage the person to seek professional help from the family doctor or a mental health worker.

• Take care of yourself. Supporting someone with depression can be demanding, so make sure you take some time out to look after yourself.

11

DEPRESSION

 

.REMEMBER
Ø Go out of your way and don’t give up on them.

Ø Just being with them, being present – even without much talking, can be very supportive and helpful.

DEPRESSION

12

Managing thoughts and self-talk

When people become depressed, they often think negatively about themselves (“What have I ever achieved?”,“I’m no good at anything”), their circumstances (“There’s no way out of
this mess”,“It’s all pointless…everything I’ve tried has just made things worse”), and the future (“Things will never really change, they’ll only get harder”).

How we think and what we say to ourselves in our head (self- talk) can have a profound effect on our mood and mental state.
It can also cause paralysis in problem-solving and decision-making.

 

Depression

   

Paralysis in problem-solving and decision-making

Negative

thoughts and self-talk

  

Worsening Depression

Becoming aware of our thoughts and self-talk, and learning the skill and habit of managing them, is essential to recovery from depression and, later on, preventing relapse.

There are basically two kinds of thought patterns we can use in responding to the things life deals out to us: one that is Self- Defeating, because it launches into negative thoughts and self-talk, and one that is Constructive and helpful, because it launches into sensible and rational thoughts and self-talk.

13

DEPRESSION

Mental Health

Consequences

− Worsened depression

− Feel angry and powerless

Self-defeating thoughts and self-talk

“I can’t even get on with my wife anymore” “Even my marriage is a failure”
“I’m useless at this like everything else”

Situation

Argument with wife

Physical Consequences

−  Feel ‘sick’

−  Knot in the
stomach

−  Feel very tense
and shaky

Behavioural Consequences
− Will give up and withdraw, perhaps even get angry and make things worse

Mental Health

Consequences

− Feel regretful but OK because things are in perspective

Physical Consequences

− Feel a bit ‘wound up’ but am becoming calm

Constructive thoughts and self-talk

“I don’t feel good about this,but we are both tense and on edge” “Our relationship is OK. We will need to work this through when we are both calm”

Situation

Argument with wife

Behavioural Consequences
− Will seek to resolve problems

and relationships

Here are some examples:

Self-Defeating Pattern

    

Constructive Pattern

   

14

DEPRESSION

People who tend to use a self-defeating thought pattern in interpreting events also develop (mostly unconsciously) errors in thinking which, like ‘jumping to conclusions’, may seem to save time and energy, but can actually have consequences that demand much time and energy.

Managing thoughts and self-talk, and adopting constructive thought patterns, are essential for achieving and maintaining good mental health. It can be achieved through:

• becoming aware of how we respond to events (and what we think and say to ourselves in our heads)

• censoring and modifying our thoughts (especially those that are automatic) and self-talk

• challenging and dismantling errors in thinking.
Becoming aware
We can simply decide to become aware of our thoughts and self- talk. This awareness provides us with the opportunity to change them; it gives us the power of censorship. With practice, it is even possible to exert in uence over our automatic thoughts (challenging and dismantling errors in thinking will help this too).
To get this awareness underway, it is helpful to do some initial documenting of situations/events to be examined, the feelings experienced, and the thoughts that occur. This is also a good way to identify errors in thinking.

15

DEPRESSION

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

An unexpected bill arrives that ‘throws’ my budget out.

‘Sick’ feeling in the pit of my stomach. Fear about how to cope with another bill.

“Everything just has to go wrong.”
“Like everything else around this place.” “There is no way we can cope with this.”

EXAMPLE

Practise ‘taking snapshots’ of situations, and write things
down like this. It can be quite revealing and is a useful way of establishing awareness. After a while, this can be expanded into the skill of censoring and modifying thoughts and self-talk.

Censoring and modifying

The key to censoring and modifying (or managing) thoughts and self-talk is the speed with which we intervene and ask ourselves: is this thought/idea (or what I’ve begun saying to myself) self-defeating or constructive? If it’s self-defeating, how can I immediately modify it or replace it so that I am using a constructive thought pattern?

This is a skill to be practised and a new habit to be formed. As with becoming aware, it can be really helpful (at least initially), to write things down. When we can ‘see’ our thoughts and what we are saying to ourselves, we have more power to change them.

16

DEPRESSION

        

17

DEPRESSION

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

A friend, who you had arranged to come over and help you with something important, has left a message to cancel.

“Why is it me that gets let down?”
“This is typical of the way things go for me.”

Self-defeating, because I have reacted negatively and feel more flat and depressed than before.

Considering:
How do I know why he had to cancel? It could have been an emergency.
I’ve cancelled things too. There are other things I can do; this can be put on hold. Everyone feels let down sometimes — that’s life.

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

“One of these days something might just go right.”

 

Challenging and dismantling errors in thinking

Errors in thinking consist of certain assumptions and ways of thinking that keep recurring, are habitual and allow us to ‘save’ time by not thinking constructively about events. They provide an easy response, but one that is neither time-saving nor helpful. Errors in thinking ‘save a penny and spend a pound,’ because their consequences heavily tax our energy reserves and contribute to depression.

Errors in thinking need to be challenged and revised if we are to establish a constructive and healthy thought pattern.

Common Errors in Thinking:

DEPRESSION

— Mind-reading: — Catastrophising:

— Labelling:

— over-generalising:

“She thinks I’m a failure;”
“They think I’m not as good as…”

“Everything always turns out bad for me;” “Things are always against me;”
“Now I will never be able to…;”
“No matter how hard I try everything always goes wrong”

“I’m an idiot;” “I’m a failure;” “I’m a lousy…” (Instead of:“I did poorly;” or “I did not achieve…;” or “I needed to…”)

Saying,“Always,” “Never,” “No-one,” or “Everyone”

18

— Fortune telling:

— ‘Rule saying’:

— Black and white thinking:

“Everyone is sure to…..;”
“I’m sure to mess it up;”
“It’s going to be a disaster;”
“I’m sure to feel dreadful when I…”

“Should,” “Must,” or “Have to” (setting sometimes unrealistic expectations)

“Everything she does she gets right;”
“I’ve completely ruined everything;”

“He succeeds in everything… I never get it right!”

Examples you can think of: —

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DEPRESSION

  

Structured Problem-Solving

It’s common for people who are depressed to feel stressed and overwhelmed by problems. Adopting a new way of tackling problems can be very helpful.

Structured problem-solving is a method designed to help you feel in control of your problems, and to enable you to deal more effectively with future problems.

The key elements of this method include:

• Identifying and ‘pinning down’ the problems that have
contributed to you feeling overwhelmed

• Thinking clearly and constructively about problems

• ‘Taking stock’ of how you’ve coped in the past: your personal strengths, and the support and resources available to you

• Providing a sound basis for important decision-making. With this method, you can work on a single problem or follow
the process to tackle a number of problems.
Usually though, it’s best to deal with one problem that is speci c and potentially solvable – especially to begin with.

DEPRESSION

20

Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly – including good and not so good options); write them down:

1.

2.

3.

4.

5.

21

DEPRESSION

1.

2.

3.

4.

5.

STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

22

DEPRESSION

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

1. a. b.

c.

d.

2. a.

b.

c.

d.

3. a.

b.

c.

d.

4. a.

b.

c.

d.

5. a.

b.

c.

d.

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________

For more information, see Fact sheet 10 Changing your thinking at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

23

DEPRESSION

Depression

 

Decreased
− Physical
− Mental and
− Social activity

Loss of energy, motivation, interest and pleasure in things

 

Activity Planning

Many people who have depression experience a loss of energy, motivation, interest and pleasure in things previously meaningful or enjoyed.

As a result, they become less physically, mentally, and socially active – which tends to worsen depression. Becoming active again is an important step in breaking the cycle of depression.

   

Activity planning aims to break the cycle of depression by methodically and gradually restoring important daily activities.

24

DEPRESSION

Achievement Activities

Daily achievements, even if only small, can help restore the lost experience of meaning and satisfaction; they can also reverse the sense of paralysis that is so common with depression.

List the activities that previously gave you a sense of achievement: Number in order of importance

•o •o •o •o •o

List work tasks that need to be done, which will give you a sense of achievement or relief to complete:

Number in order of importance

•o •o •o •o •o

25

DEPRESSION

 

Social Activities

People who are depressed commonly withdraw from family, friends, and important social activities. Social isolation, which can quickly set in, only serves to worsen depression and make recovery more dif cult.

Doing things with other people, even if it doesn’t feel comfortable at rst (and even if you have to drive a long distance), can help motivate you, lift your mood, and improve your general state of mind. It is important to decide to accept social invitations and to pursue opportunities for social contact and activities.

List the social contact and activities that used to be important to you:

Number in order of importance

•o •o •o •o •o

DEPRESSION

26

List the family and friends you need to reconnect with or spend more time with:

Number in order of importance

•o

•o

•o

•o

•o Pleasant Activities

People who are depressed often lose interest and pleasure in things they once liked doing.

It is vital to recovery from depression, to plan activities that can again be a source of enjoyment, pleasure and satisfaction.

List activities that you would normally nd enjoyable, interesting relaxing or satisfying:

Number in order of importance

•o •o •o •o •o

27

DEPRESSION

 

Physical Activities

Regular daily exercise can be a powerful antidote for depression. Ideally this should be done early in the day and in the sunlight. Certainly, manual work provides exercise; but the best kind of physical activity for depression is separate from work, and purely dedicated to improving physical and mental health.Walking, cycling, using weights or an exercise machine, for example, even if only for 15 minutes a day, can be quite bene cial.

Bearing in mind any medical condition or physical limitations you might have, list physical/exercise activities you have done in the past:

Select one of these to recommence

•o •o •o •o •o

Now that you have listed and prioritised all the activities that are important for your recovery from depression: Achievement, Social, Pleasant, and Physical Activities, put your number one selections into your diary (or Daily Activities Diary provided).

DEPRESSION

28

Tips for Successful Activities Planning

• Whenever possible put one of each of these activities into your diary each day.

• ‘Don’t bite off more than you can chew;’ better to achieve small goals than to feel a failure because of attempting too much.

• If you start an activity or task and ‘run out of steam,’ or for some other reason can’t commence it or complete it, that’s ne. Simply reschedule it for the next day or another suitable time.

• Try to be sure you have the day’s activity plan completed the evening before, or in advance, so that you have a plan of action to follow immediately when you get up.

29

DEPRESSION

                        

DAILY ACTIVITIES DIARY

Physical

Time SUnDAY 8.00am
9.00am
10.00am

MonDAY

TUESDAY

WEDnESDAY

11.00am 12.00noon 1.00pm 2.00pm 3.00pm 4.00pm 5.00pm 6.00pm 7.00pm 8.00pm 9.00pm 10.00pm

Achievements Social Pleasant

DEPRESSION

30

                     

31

DEPRESSION

DAILY ACTIVITIES DIARY continued.

Time THURSDAY 8.00am
9.00am
10.00am

FRIDAY

SATURDAY

11.00am 12.00noon 1.00pm 2.00pm 3.00pm 4.00pm 5.00pm 6.00pm 7.00pm 8.00pm 9.00pm 10.00pm

  

Reducing Alcohol Consumption to a Moderate Level

Many people ‘drown their sorrows’ and try to escape problems and feelings of depression through the use of alcohol.

The problem is that any relief alcohol does provide is short-lived. Alcohol is actually a depressant drug – it spoils the quality of sleep and interferes with the effects of antidepressant medication.

Strategies for moderating drinking

• Try to avoid drinking at home alone – especially when you are feeling down or anxious.

• Try limiting your drinking to the evening meal time.

• Drink low-alcohol beers and mixes.

• Drink slowly (limit yourself to 2 standard drinks each day).

• Think ahead (and creatively) about how to avoid drinking excessively in situations (like the pub or social gatherings) where there is pressure to do so.

• Use your Daily Activity Diary to plan two alcohol-free days each week. Try to choose days when it is easiest to do so; like when an activity is planned for the evening that can be a useful distraction.

• Decide beforehand how much alcohol you will permit yourself to drink; measure it out, and only allow yourself that amount.

• Always try to stay within the Australian Alcohol Guidelines.

DEPRESSION

32

For Men and Women

over a lifetime: If you drink no more than 2 standard drinks a day, you reduce the lifetime risk of harming yourself from alcohol-related disease or injury.

on a single occasion: Having no more than 4 standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.

NUMBER OF STANDARD DRINKS – BEER

        

1.1

285ml
Full Strength 4.8% Alc. Vol

0.8

285ml Mid Strength 3.5% Alc. Vol

0.6

285ml Low Strength 2.7% Alc. Vol

1.6

425ml
Full Strength 4.8% Alc. Vol

1.2

425ml Mid Strength 3.5% Alc. Vol

34

24 x 375ml

Full Strength 4.8% Alc. Vol

0.9

425ml Low Strength 2.7% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

1.4

375ml
Full Strength 4.8% Alc. Vol

24

1

375ml Mid Strength 3.5% Alc. Vol

0.8

375ml Low Strength 2.7% Alc. Vol

     

1.4 1 0.8

19

24 x 375ml Low Strength 2.7% Alc. Vol

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE

      

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Red Wine 13.5% Alc. Vol

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

      

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

33

DEPRESSION

NUMBER OF STANDARD DRINKS – SPIRITS

       

1

30ml High Strength Spirit Nip 40% Alc. Vol

1

250ml Full Strength Pre-mix Spirits 5% Alc. Vol

22

700ml High Strength Bottle of Spirits 40% Alc. Vol

1.2

300ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.1

275ml Full Strength RTD* 5% Alc. Vol

1.2

330ml Full Strength RTD* 5% Alc. Vol

2.6

660ml Full Strength RTD* 5% Alc. Vol

1.5

275ml High Strength RTD* 7% Alc. Vol

1.8

330ml High Strength RTD* 7% Alc. Vol

3.6

660ml High Strength RTD* 7% Alc. Vol

       

australian guidelines to reduce health risks from dri

1.5

375ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.7

440ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.4 – 1.9

250ml
High Strength Pre-mix Spirits 7% – 10% Alc. Vol

1.6

2.1

2

.4

Guideline 1: Reducing the risk of alcohol-

re

lated

300ml High Strength Pre-mix Spirits 7% Alc. Vol

375ml High Strength Pre-mix Spirits 7% Alc. Vol

440ml High Strength Pre-mix Spirits 7% Alc. Vol

Men Women

1 in 100

 

For more information, see Fact sheet 9 Reducing alcohol and

other drugs at http://www.beyondblue.org.au or call the beyondblue info line lcohol-related injury 1300 22 4636

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

* Ready-to-Drink

11 10 9 8 7 6 5 4 3 2 1 0

Lifetime risk of death from alcohol-related disease per 100 drinkers, by number of

nking alcoho

harm over a lifetim

              

1 2 3 4 5 6 7 8 9 10 Standard drinks

figure 5 lifetime risk of death from alcohol-related disease per 100 drinkers, by number

standard drinks per occasion, Australia 2002

of standard drinks per occasion, australia 2002

For people who regularly drink 2 standard drinks per day, the lifetime risk of

Source: Rehm et al (2008)

death from an alcohol-related disease is about 0.4 in 100 people with that

drinking pattern. Above that level, the risk increases with the number of drinks

per day, and is above 1 in 100 at 3 drinks per day. The risk increases more sharply

for people who regularly drink two standard drinks per day, the lifetime risk of death from

for women than for men.

an alcohol-related disease is about 0.4 in 100 people with that drinking pattern. above that

Source: National Health and Medical Research Council Australian Guidelines to Reduce Health Risks

level, the risk increases with the number of drinks per day, and is above 1 in 100 at three

from Drinking Alcohol, Canberra: Commonwealth of Australia, 2009.

drinks per day. the risk increases more sharply for women than for men.

a

Basis and quality of the evidence

34

Lifetime risk of death from alcohol-related injury

A modelled analysis (Rehm et al 2008) was used to determine the

Lifetime risk per 100 drinkers

DEPRESSION

Managing stress

Emotional stress and acute distress have been identi ed as signi cant contributing factors to depression. However, trying to create a stress-free life would be both unrealistic and undesirable, since stress is associated with work, family and personal relationships – in fact with nearly all the changes and challenges that enable us to develop, adapt, and make our way successfully through life.

The problem arises when we experience too much stress – particularly at one time. For people who are depressed, too many sources of stress (or stressors) can worsen and prolong their depression. Consequently, nding ways of reducing and managing stress may be very important.

Ways of reducing stress

• Postponing major life changes

Some major life changes may be unavoidable. But it is best to postpone changes that are likely to generate stress and upheaval, if possible.

• Learning to relax

Think of the things that help you relax, and set aside time in the day to do more of them. Also, be sure to get enough rest and sleep each day.

• Regular daily exercise

Find a form of gentle exercise (apart from work) that you enjoy and can keep doing on a regular basis.

• Learn to say no and set priorities

You may need to say “no” more often to new commitments, and instead concentrate on your activities plan.

35

DEPRESSION

For more information, see Fact sheet 6 Reducing Stress at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

36

• Work on your relationship
One of the most common contributors to long-term depression is tension and con ict in personal relationships. You may need to devote more time to ‘greasing the gears’ and resolving issues in your relationships. If you have access to a skilled counsellor, that could help a lot. If not, there are useful self-help books available in book stores and libraries, and information on the internet.

• Use Financial Advisory Services or Rural Counselling
Financial dif culties can be hugely stressful and are one of the leading causes of relationship breakdown. Using the expertise and more objective view of a nancial advisor
or rural counsellor can make a very real difference to how people view and tackle nancial hardship or pressure. Even when there appear to be no easy solutions, getting things into perspective, being clear about options, and getting a chance (perhaps for the rst time) to speak about how dif cult things are, can signi cantly reduce feelings of powerlessness and stress.

• Use the other self-help ideas in this book
See chapter on Stress (page 177).

DEPRESSION

Restoring a Normal Pattern of Sleep

Sleep disturbance is common with depression, and frequently takes the form of early-morning wakening (usually around 3am) with dif culty returning to sleep. To restore a normal pattern of sleep, it’s important to practise sleep-promoting behaviour during the day, in the evening, at bedtime, and during the night.

Better Sleep Guidelines

During the Day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns.

• Set aside time for problem-solving and decision-making during the day, to avoid worry or anxiety at night (see Structured Problem-Solving on page 20).

• Avoid napping during the day, go to bed and get up at regular times.
During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your Daily Activities Diary, to be dealt with tomorrow.

• Light exercise early in the evening may help sleep. Avoid exercise late in the evening, as this may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

 

37

DEPRESSION

 

• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa, and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep, and keep your intake moderate (limit yourself to 2 standard drinks each day). Have 1 or 2 alcohol-free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or too warm.

• Ensure that your bedroom is dark and that the morning light does not lter in. However, if you have a tendency to oversleep, it may be helpful to let the morning light into the room.

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack may help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation included on page 53). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t watch TV or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual activity).

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready. Enjoy relaxing your mind and body, even if you don’t fall asleep at rst.

DEPRESSION

38

During the night

• If you wake up too early in the night, don’t lie awake
for more than 30 minutes. Instead of just being awake
or worrying, get out of bed and do something that is distracting yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, use earplugs to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.
national Help/Information Lines

• beyondblue info line: 1300 22 4636 (local call cost)

• Lifeline: 13 11 14

• Kids Help Line: 1800 55 1800

• MensLine Australia: 1300 78 99 78

• Australian Psychological Society Referral Line: 1800 333 497

• SANE Australia: 1800 18 7263 (national)

• Suicide Call Back Service: 1300 659 467
See Key Services and Resources on pages 302 to 319 for state and territory contacts.

For more information, see Fact sheet 7 Sleeping well at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

39

DEPRESSION

DAepnrxeisestiyon

41

For more information, see ‘Anxiety’ at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

Warning signs of ANXIETY

Tickþthe signs that are familiar:
q Feeling ‘on edge’ or ‘wound up’ much of the time qConstantly worried about a lot of things
qFeeling irritable frequently
qTense or nervous much of the time
qAvoiding people and social situations
q Trembling, tingling, light-headedness, dizzy spells, sweating,

urinary frequency, diarrhoea
qFeeling panicky in some situations
qSleeping poorly/having dif culty falling asleep
qHaving dif culty relaxing
q Fear of making a fool of yourself socially, or of other people

watching you or drawing attention to you
qUsing alcohol or sedatives to calm down or to get to sleep qFear of having a serious illness that the doctor can’t detect q Fear of experiencing again the feelings of a past traumatic event qWorrying a lot about your health
q Fear of dying, going mad, or having something bad happen qHaving thoughts that are hard to control
q Fear of being in a place that you can’t get out of, or that you

can’t get out of without embarrassment
qFear of germs or infection
q Compulsively checking, counting or cleaning things
q Headaches, neck aches, chest pain, joint pain, or nausea qTiredness or fatigue

If you have some of these symptoms and they are affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor.

See page 3 for National Help/Information Lines.

   

42

ANXIETY

About Anxiety The ‘Fight or Flight’ response

Most people experiencing problems with anxiety visit their doctor because of worrying physical symptoms. It is important to understand that the symptoms of anxiety, rather than suggesting evidence of an underlying physical problem, are actually the result of what has been termed the ‘ ght or ight’ response.

When we are threatened by something or are in danger, our bodies respond with a series of biochemical changes aimed at preparing us to ght or escape. This harks back to our more primitive past, when people frequently needed quick bursts
of energy, as their bodies prepared to ght off or ee from ferocious predators or enemies. This remains an important response when we are faced with a real threat or danger. The problem is, our brain (in activating the ‘ ght or ight’ response) does not distinguish between what is real or what is imagined.

Many novice public speakers would confess that giving a speech
– even to a sympathetic audience – can generate as much terror and anxiety as any real physical danger or threat.What we imagine or perceive as threatening, and the way we anticipate problems or challenges in the future, whether real or not, may be ‘real’ enough for our brain to activate a response.

 

43

ANXIETY

Changes that occur due to the ‘Fight or Flight’ response

• The mind becomes alert.

• Bloodclottingabilityincreases,preparingforpossibleinjury.

• Heart rate speeds up and blood pressure rises.

• Sweating increases to help cool the body.

• Bloodisdivertedtothemuscleswhichtensereadyforaction.

• Digestion slows down.

• Saliva production decreases causing a dry mouth.

• Breathing rate speeds up – nostrils and air passages in
lungs open wider to get in air more quickly.

• Liver releases sugar to provide quick energy.

• Sphincter muscles contract to close the openings of the
bowel and bladder.

• Immune responses decrease (which is useful in the short-
term to allow massive response to immediate threat, but
can become harmful over a long period).

• Fear and apprehension

• Trembling or shaking

• Restlessness

• Cold and clammy hands

• Hot ushes or chills

• Feeling sick or nauseous

• Butter ies in the stomach
Excerpt from: Management of Mental Disorders Third edition (Australia, World Health Organization Collaborating Centre For Mental Health And Substance Abuse, 2000) Volumes 1 & 2.

Mild to moderate levels of anxiety – of ‘ ght or ight’ arousal – are normal, and can energise us, improve our thinking, reactions, and general performance. Too much anxiety, especially if it is prolonged, has the opposite and negative effect of diminishing our ability to cope and interfering with our lives.

44

ANXIETY

Situation or event that is perceived as dangerous or threatening

Brain activates fight or flight response

A series of biochemical changes occur in the body to prepare for conflict or escape

     

Anxiety Disorders

There are many types of anxiety disorders, each with a range of symptoms. Common anxiety disorders are:

Generalised Anxiety Disorder (GAD)

People who have GAD feel anxious on most days for at least six months. Generally, they worry about real issues such as nances, illness or family problems − to the point where it interferes with functioning from day to day.

Phobia

When a person has a phobia, he/she feels very fearful about particular objects or situations. Common examples include fear of social situations such as parties and meetings (social phobia) or fear of open spaces such as parks and big shopping centres (agoraphobia).

obsessive Compulsive Disorder (oCD)

Obsessive Compulsive Disorder gets its name because people who experience it have ongoing unwanted/intrusive thoughts and fears that cause anxiety called obsessions.These obsessions make people feel they need to carry out certain rituals in order to feel less anxious and these rituals are known as compulsions. Common obsessions may include fear of forgetting to do things, fear of germs/contamination, whereas compulsions may include constant checking behaviour and constant washing of hands.

45

ANXIETY

For more information, see Recovery From Trauma chapter on page 104

Panic Attacks/Disorder

Panic Disorder is diagnosed when a person experiences panic attacks. A panic attack is an intense feeling of anxiety that is overwhelming and dif cult to manage. Panic attacks have been likened to the experience of having a heart attack and may include shortness of breath, feeling lightheaded and/or nauseous or having chest pains.

Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD)
ASD and PTSD are a set of reactions that can develop in people who have experienced or witnessed a traumatic event. Traumatic events involve life-threatening situations or serious injury that lead to feelings of intense fear, helplessness or horror, e.g. assault, war, serious accident, natural disaster. It is estimated that around 5% of people experience PTSD in their lives.

The Anxiety pages on the beyondblue website http://www.beyondblue.org.au will take you step-by-step through:

• types of anxiety disorders

• how to recognise signs and symptoms

• how to get help and treatment for yourself or someone you know

• how to stay well.
Other beyondblue anxiety information material available: beyondblue Fact sheet 21 – Anxiety Disorders
beyondblue Fact sheet 31 – Post-Traumatic Stress Disorder beyondblue Fact sheet 35 – Generalised Anxiety Disorder beyondblue Fact sheet 36 – Panic Disorder
beyondblue Fact sheet 37 – Obsessive Compulsive Disorder beyondblue Fact sheet 38 – Speci c Phobias
beyondblue Fact sheet 39 – Social Phobia
beyondblue wallet-size information card – Anxiety Disorders beyondblue envelope-size information card – Anxiety Disorders

  

46

ANXIETY

Anxiety can be very disabling

In a recent Australian Bureau of Statistics survey, around
1 in 7 people indicated that they were experiencing symptoms consistent with an anxiety disorder. People with anxiety disorders reported being unable to carry out their usual roles and tasks.

People with anxiety problems are also at increased risk of developing depression (2-4 times higher than people without
a history of anxiety). Anxiety disorders pre-date depression in most cases and more often than not, anxiety and depression are found together when depression is diagnosed.

What if anxiety is left untreated?

Left untreated, a problem of anxiety is likely to continue and worsen with signi cant life-diminishing consequences. As already mentioned, people with moderate to severe anxiety problems are at increased risk of developing depression.

The outlook for people with anxiety who do receive treatment is generally very good. But, just as with depression, people with anxiety will need to be actively involved in their treatment, mastering new skills and adopting changes in lifestyle.

 

47

ANXIETY

You can find more information about anxiety medication at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

What are the treatments for anxiety?

For mild to severe anxiety disorders, psychological therapy is the basis of treatment. Medication can be useful, especially for severe anxiety, or when there are repeated episodes of panic or obsessional thinking.

Medication

One of the most common medications used to treat anxiety is also used to treat depression. Its technical name is Selective Serotonin Reuptake Inhibitor (SSRI). SSRIs are also frequently used when anxiety and depression appear together.

Psychological Therapy

Even when drugs are prescribed, psychological therapy is an indispensable part of treatment. The therapies and strategies widely used and found to be most helpful for treating anxiety disorders include:

• controlled breathing (because over-breathing is generally a problem with anxiety)

• relaxation

• adopting constructive thought patterns

• structured problem-solving

• restoring a pattern of normal sleep

• graded exposure

• reducing alcohol and caffeine consumption.
If a suitable health professional is unavailable in your area, you may access therapy online. Options for online support are found at http://www.beyondblue.org.au (click on Get help/Links/E-health). Your doctor may recommend the use of medication and the self-help version of these therapies (along with other strategies) mentioned in this resource book.
48

  

ANXIETY

Though these self-help ‘therapies’ do re ect (and are a simpli ed form of) the therapies used by trained psychotherapists, they
are not intended as a substitute for seeing a doctor, or for psychological therapy when that is what the doctor strongly recommends. In the case of a severe anxiety disorder (especially if it has particularly dif cult features), it may be recommended and necessary to travel to where psychological therapy is available.

MEDICARE REBATES

A rebate can be claimed through Medicare for ‘Psychological Therapy’ or ‘Focused Psychological Strategies’ when a GP, psychiatrist or paediatrician refers a person to a clinical psychologist, registered psychologist, social worker or occupational therapist in mental health.A rebate can

be claimed for part of the cost of up to 12 individual consultations (more in exceptional circumstances) and
12 group sessions in a calendar year. If the mental health practitioner bulk-bills, there will be no upfront charge and therefore no reason to claim a rebate.

For more details, ask your referring medical practitioner
or see beyondblue Fact sheet 24 – Help for depression, anxiety and related disorders under Medicare.

For a list of health professionals with expertise in treating depression, go to the beyondblue website: http://www.beyondblue. org.au and click on Find a Doctor or other Mental Health Practitioner or call the beyondblue info line on 1300 22 4636.

   

49

ANXIETY

Some of the symptoms of over-breathing

• Light-headedness

• Blurred vision

• Feeling strange

• Increased heartbeat

• Stiffness, twitching, or cramps in muscles

• Breathlessness
• Confusion
• Irregular heartbeat • Cold, clammy hands

• Numbness and tingling in hands or feet

Because over-breathing is hard physical work, a person may feel:

• Hot, ushed and sweaty

• Tired and exhausted.
Over-breathing may over-use chest muscles resulting in:

• Chest tightness
• Severe chest pain.

Controlled Breathing

The ‘ ght or ight’ response associated with anxiety (see
page 43) creates an increase in the rate of breathing (called hyperventilation). This over-breathing gives rise to a whole range of symptoms:

 

Over-breathing is not always obvious to the observer or even to the anxious people themselves. It can be very subtle – especially if the individual has been slightly over-breathing for a long period of time. Mild over-breathing can cause a person to be in a constant state of fearfulness and anxiety.

Over-breathing is especially associated with the experience of panic and may act as the initial prompt causing an individual to panic.

50

ANXIETY

One proven way of managing and reducing the symptoms of over- breathing is by using a controlled or slow breathing technique.

Controlled Breathing Technique

1. Breathe in (without taking a deep breath) and hold your breath for a count of 5.

2. When you get to 5, gently breathe out saying to yourself “relax” or “calm”.

3. Then just breathe in and out slowly, through your nose, counting 3 with each breath in, and 3 with each breath out.

4. Breathe this way for about 10 breaths, and then start the cycle again by holding your breath and counting to 5 (step 1).

5. Continue this controlled breathing cycle until all the symptoms of over-breathing have gone.

Tips on the use of the Controlled Breathing Technique

• Use the technique immediately the rst signs of over- breathing, panic, or growing anxiety occur.

• Practise the technique at least 4 times each day.

• ‘Over-learn’ the technique (practise it until it becomes an automatic response), so that it can be used quickly to prevent anxiety escalating.

• Spend enough time practising the technique for it to feel comfortable.

• Practise the technique whenever you notice sensations of anxiety.

51

ASNTXRIESTSY

Relaxation

The same mechanism that turns on the anxiety response can also switch it off again. When we decide to let go of physical
and mental tension (and take steps to do so), the nerves in our muscles change the type of signals they transmit to the brain.The brain then stops sending panic messages to our nervous system, and a general feeling of calmness, both physical and mental, begins to prevail.The relaxation response can help switch off the ght or ight anxiety response.

For people who are often anxious, there is little opportunity for high levels of muscle tension to diminish. The consequence of living with a high level of tension is that a state of tension becomes ‘normal’ and is taken for granted – so that being tense isn’t noticed.

Becoming aware of tension in our body, and taking steps to release it through effective relaxation, is a vital strategy in the management of anxiety.

  

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Recognising Tension

Ask yourself these questions:

• Where do I feel tension?
– In which parts of my body? – In which muscles?

• What does the tension feel like? – Is there hardness?
– Is there fatigue?
– Is there an ache or pain?

• What is it that has led to this tension?

• Is this tension helpful or unhelpful?

• Do I need to make time to relax?

Progressive Muscle Relaxation*

A method of relaxation with proven effectiveness which relieves muscle tension, and can help switch off the ‘ ght or ight’ anxiety response, is progressive muscle relaxation. This involves tensing and then relaxing muscles in a step-by-step sequence.The two main principles of this technique include:

1. Tensing muscle groups (one at a time) to become aware of the feeling of tension.

2. Relaxing the muscles and feeling the tension in them subside – as if owing out of the body.

* Adapted from: Davis, M., et al. The Relaxation and Stress Reduction Workbook Fourth edition (U.S.A., New Harbinger Publications, 1995).

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Progressive Muscle Relaxation

• You will need about 15 minutes for this relaxation exercise.

• Find a quiet place where you won’t be interrupted.

• Sit in a comfortable straight-backed chair, with your feet at on the oor.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Tense each of the following muscle groups for 5 seconds, then relax them completely for 15-20 seconds (pay particular attention to the different sensations of tension and relaxation):

1. Curl both your sts and tighten your biceps and forearms (as if lifting weights). Relax.

2. Wrinkle up your forehead; tighten the muscles in your face causing your face to wrinkle; purse your lips and press your tongue against the roof of your mouth; hunch your shoulders. Relax.

3. Arch your back as you take a deep breath into your chest. Relax.

4. Taking a deep breath, gently push out your stomach. Relax.

5. Pull your feet and toes backwards tightening your shins. Relax.

6. Curl your toes at the same time as tightening your calves, thighs and buttocks. Relax.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Now resume normal activities in a calm and peaceful manner.

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Tips and cautions on the use of progressive muscle relaxation

• Be patient with yourself and this technique. You may only experience partial success at rst. In time, it should be possible for you to relax your whole body quickly and successfully. Practise is the key.

• Be careful when you are tensing your neck and back. Don’t tighten your muscles beyond what feels comfortable for you.

• To achieve the best results with this technique it’s important to let go of the tension in a group of muscles you have tensed instantly. Releasing tension slowly may seem to relax muscles, when in fact it may just sustain tension. When you release muscle tension, do it instantly and let the muscles suddenly become limp.
other relaxation techniques
There are many relaxation techniques that people nd helpful, such as meditation, yoga, self-hypnosis and relaxation music combined with guided imagery or visualisation.These and many other techniques and resources are available from book shops, music stores, the internet and local or mobile libraries.

For more information, see Fact sheet 6 Reducing stress at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

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Adopting a Constructive Thought Pattern

What we perceive as dangerous or threatening activates the ‘ ght or ight’ response. When this perception changes – either because the danger or threat ceases, or because we alter the way we think about or interpret it (“this is not a threat or danger to me”), the ‘ ght or ight’ response is deactivated or turned off.

How we interpret life events (the things that happen to us, challenge us, make demands of us, or that we perceive may have consequences for us), has a huge bearing on how much stress or anxiety we experience.

Part of this interpreting is what we think, how we think and what we say to ourselves in our head (our self-talk).

The kind of thought pattern or way of interpreting events that we use is generally either self-defeating or, alternatively, constructive.

Self-defeating interpretations (thoughts and self-talk) can generate high and unhealthy levels of stress or anxiety – as well as causing paralysis in attempts at problem-solving and decision-making.

Constructive interpretations (thoughts and self-talk) help to maintain healthy and useful levels of stress or anxiety, which permit and promote coping.

  

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Self-Defeating Interpretation

Self-defeating thoughts and self-talk

“I can’t even get on with my wife any more” “Even my marriage is a failure”

“I’m useless at this like everything else”

Event

Argument with wife

Experience

High level of stress/anxiety, causing difficulty in coping

   

Behavioural Consequences
− Will give up and withdraw, perhaps even get angry and make things worse

Constructive Interpretation

Constructive thoughts and self-talk

“I don’t feel good about this, but we are both tense and on edge”
“Our relationship is OK. We will need to work this through when we are both calm”

Experience

Moderate level
of stress/anxiety, permitting and promoting coping

Event

Argument with wife

   

Behavioural Consequences
− Will seek to resolve problems

and relationships

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Self-defeating interpretations also tend to become more entrenched, and stress or anxiety levels more unhealthy and unhelpful, as a self-reinforcing vicious cycle develops.

People who tend to use a self-defeating thought pattern in interpreting events also develop (mostly unconsciously) errors in thinking which, like ‘jumping to conclusions,’ may seem to save time and energy, but can actually have consequences that demand much time and energy.

Adopting a constructive thought pattern in interpreting events is essential for managing stress or anxiety, and for achieving and maintaining good mental health.

How can this be done? It can be achieved through:

• becoming aware of how we respond to events
(and what we think and say to ourselves in our heads)

• censoring and modifying our thoughts (especially those that are automatic) and self-talk

• challenging and dismantling errors in thinking.

    

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Becoming aware

We can simply decide to become aware of our thoughts and self-talk.This awareness provides us with the opportunity to change them; it gives us the power of censorship.With practise, it’s possible to even exert in uence over our automatic thoughts (challenging and dismantling errors in thinking will help this too).

To get this awareness underway, it’s helpful to do some initial documenting of situations/events to be examined, the feelings experienced and the thoughts that occur. This is also a good way of identifying errors in thinking.

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

You discover one of your vehicle tyres is flat, and you were organised to go somewhere.

Immediate ‘welling up’ of stress and anxiety, then strong feelings of anger.

“No!” “Everything just has to go wrong;” “Like everything else around this place;” “I just don’t need this.”

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

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Practising taking ‘snapshots’ of situations and writing things down like this, is a useful tool for establishing awareness. After a while this can be expanded into the skill of censoring and modifying thoughts and self-talk.

Censoring and modifying

The key to censoring and modifying (or managing) thoughts and self-talk is the speed with which we intervene and ask ourselves: Is this thought/idea (or what I’ve begun saying to myself) self-defeating or constructive? If it is self-defeating, how can I immediately modify it or replace it so that I am using a constructive thought pattern?

This is a skill to be practised and a new habit to be formed. As with becoming aware, it can be really helpful (at least initially), to write things down; when we can ‘see’ our thoughts and what we are saying to ourselves, we have more power to change them.

 

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Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

A friend, who you had arranged to come over and help you with something important, has left a message to cancel.

“Great;” “Thanks a lot;” “Why is it I always get let down?”

Self-defeating, because I can feel stress and anger building up.

How do I know why
he cancelled….it could
have been an emergency. Everyone feels let down sometimes, that’s life. I’ve cancelled things too.
There are other things I can do; this can be put on hold. It’s all right.

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Examples of common errors in thinking

Challenging and dismantling errors in thinking

Errors in thinking consist of certain assumptions and ways of thinking that keep recurring, are habitual, and allow us to save time by not thinking constructively about events.They provide
an easy response, but one that is neither time saving nor helpful. Errors in thinking ‘save a penny and spend a pound,’ because their consequences heavily tax our energy reserves, and generate high and unhealthy levels of stress or anxiety.

Errors in thinking need to be challenged and revised if we are to establish a constructive and healthy thought pattern.

Assumptions

All things are equally important and urgent

Challenge

Many things are not crucial or urgent. But they generate anxiety because I interpret them that way.
Some things are crucial and/ or urgent and cannot be left. Many things are not, and they can be postponed.

If I’m stressed or anxious, what does a thing matter, unless it is truly crucial or urgent?
This is not inevitable or necessary, it is a habit. Lots of other people take these things pretty much in their stride. No, getting uptight often

is mostly because I often interpret events in a self- defeating way.

   

Getting uptight about unforeseen or unwanted events is inevitable

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Everything has to go wrong. Life is against me succeeding

Based on what evidence? What about people who, against all apparent odds, still succeed? Do I need to examine how

I go about things? How I make decisions, and for what reasons?
If I expect things to go wrong, isn’t it highly likely I will contribute to that happening? Has ‘life’ really singled me out to be a victim?

What real evidence supports this assumption?
Are other people let
down also? How does my experience compare with theirs?

Have I on occasions let others down?
Do I know anyone who always experiences other people as completely reliable?

Do I automatically believe the best or the worst when people appear to let me down? Are my expectations reasonable?

 

People always let me down

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ANXIETY

 

If I could go back in time: If I had…
If only I did…

The benefit of hindsight is a fine thing. Of course I could be more knowledgeable, skilled and wise if I could have been then who I am now,or if I could go back as who I am now.
How is this kind of thinking helpful?
I was who I was. I made decisions and did things as the person I was, and was capable of being then. No amount
of lamenting will change that. The only valid questions are perhaps:What can I learn
from the past? What can I
do differently now and in the future?

No one could live up to that, without lying about the many occasions when they, quite rightly, didn’t bother to do some things either perfectly or properly. Taking pride in doing important things well is admirable. But trying to

do everything perfectly or properly is not necessary, important, reasonable, or admirable. It is plain unhealthy! Perhaps what is more needful is to be able to prioritise?

  

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Everything has to be done perfectly or properly

64

other thinking habits:

— Mind-reading: — Catastrophising:

— Labelling:

— over-generalising: — Fortune-telling:

— ‘Rule-saying’:

— Black and white — thinking:

“She thinks I’m a failure;”
“They think I’m not as good as….”

“Everything always turns out bad for me;”
“Things are always against me;”
“Now I will never be able to….;” “No matter how hard I try everything always goes wrong.”

“I’m an idiot;” “I’m a failure;” “I’m a lousy…..” (Instead of “I did….poorly;” or “I did not achieve…..;” or “I needed to….”)

Saying,“Always,” “Never,” “No-one,” or “Everyone.”

“Everyone is sure to…..;”
“I’m sure to mess it up;”
“It’s going to be a disaster;”
“I’m sure to feel dreadful when I…..”

“Should,” “Must,” or “Have to” (setting sometimes unrealistic expectations).

“Everything she does she gets right;” “I’ve completely ruined everything;” “He succeeds in everything…… I never get it right!”

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Examples you can think of: —

 

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Structured Problem-Solving

For people who are anxious, it is common to feel threatened and overwhelmed by problems, and the thought of having to deal with them. So it can be really helpful to have a step-by-step methodical way of dealing with problems and making decisions. Through the method of structured problem-solving, it is possible to feel more in control of problems and to signi cantly reduce the feeling of being threatened or overwhelmed by them.

The key elements of this method include:

• Identifying and ‘pinning down’ the problems that have
contributed to you feeling overwhelmed

• Thinking clearly and constructively about problems

• ‘Taking stock’ of how you’ve coped in the past: your personal strengths, and the support and resources available to you

• Providing a sound basis for important decision-making. With this method you can work on a single problem or follow
the process to tackle a number of problems.
Usually though – especially to begin with − it is best to deal with one problem that is speci c and potentially solvable.

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1.

2.

3.

4.

5.

Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly − including good and not so good options); write them down:

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STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

1.

2.

3.

4.

5.

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1. a.

b.

c.

d.

2. a.

b.

c.

d.

3. a.

b.

c.

d.

4. a.

b.

c.

d.

5. a.

b.

c.

d.

For more information, see Fact sheet 10 Changing your thinking at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________

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Restoring a Pattern of Normal Sleep

Sleep disturbance is common with anxiety – particularly the problem of not being able to get off to sleep at night. To achieve a pattern of normal sleep, it is important to practise sleep-promoting behaviours during the day, in the evening, at bedtime, and during the night.

Better Sleep Guidelines

During the Day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns.

• Set aside time for problem-solving and decision-making during the day to avoid worry or anxiety at night (see Structured Problem-Solving included on page 67).

• Avoid napping during the day – go to bed and get up at regular times.
During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your diary, to be dealt with tomorrow.

• Light exercise early in the evening may help sleep. Avoid exercise late in the evening, as this may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

 

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• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep and keep your intake moderate (limit yourself to 2 standard drinks each day). Have 1 or 2 alcohol-free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or too warm.

• Ensure that your bedroom is dark and that the morning light does not lter in. However, if you have a tendency to oversleep, it may be helpful to let the morning light into the room.

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack might help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation on page 53). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t watch TV or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual activity).

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready. Enjoy relaxing your mind and body, even if you don’t at rst fall asleep.

 

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During the night

• If you wake up too early in the night, don’t lie awake
for more than 30 minutes. Instead of just being awake
or worrying, get out of bed and do something that is distracting yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, have earplugs handy to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.

For more information, see Fact sheet 7 Sleeping well at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

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Gradual (graded) Exposure Anxiety resulting in avoidance and leaving

For people who are anxious, feeling noticeably or uncomfortably anxious in a particular situation can become associated with that or similar situations. Before long, they may begin to avoid these situations (for fear of becoming anxious); or, nding themselves in such situations, they may quickly leave (again, for fear of becoming anxious, or because they expected to be anxious, and that is what happened).

Unfortunately, both avoidance and leaving behaviours can make the problem of anxiety worse, because despite providing a feeling of relief and a drop in anxiety, these behaviours make it more and more dif cult to face the situations that are feared. Two main problems arise with avoidance and leaving:

• Because it is not always possible to avoid feared situations, it can become very distressing when a person is forced to face them.

• Frequently avoiding feared situations, a person begins to tolerate less and less anxiety, avoiding an ever-widening number of potentially anxiety producing situations. This can become quite disabling, and signi cantly affect lifestyle and daily living.

   

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Confronting fears through Gradual (graded) Exposure

A way of overcoming a fear of objects or situations that has proven to be successful in psychological therapy is confronting and facing fears using a method of gradual or graded exposure.

When things that are feared are confronted for long enough, fear eventually subsides, and the fear experienced in that situation next time around will be less. An important way of breaking
the pattern of avoidance and leaving behaviour is by gradually confronting things that are feared, starting with easy situations and slowly building up the con dence and resilience to face the harder things. Part of, and essential to, this process of gradual exposure is remaining in the feared situation until there is a clearly experienced decrease in anxiety. It is also critical to success that the person experiencing anxiety use the controlled breathing technique and relaxation, prior to each occasion of gradual exposure, to limit their initial anxiety and to build their con dence in the achievability of each progressive step towards achieving their goal.

Controlled breathing can easily be practised while in the feared situation, as can relaxation, by noticing tension in particular muscles, and consciously tensing and relaxing them (as in the technique of Progressive Muscle Relaxation).

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2. List the situations that make you feel panicky or fearful:

Number each one in order, from least feared to most feared

Gradual (graded) Exposure

IMPORTANT

1. Use the controlled breathing and relaxation techniques to prepare for each step and to manage your anxiety in each feared situation.

…………………………………………………………………………………………… o …………………………………………………………………………………………… o …………………………………………………………………………………………… o …………………………………………………………………………………………… o

3. Choose one of these situations (preferably the least feared) that you think you can cope with:

…………………………………………………………………………………………….. 4.

Write down the specific fears you have about this situation:

If any of these fears are exaggerated, write down what you think is more likely to happen:

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76

5. Plan a series of gradual steps for confronting/facing the feared situation, starting with small, not too threatening steps, progressing to more difficult ones:

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8

      

REMEMBER

• Just as anxiety rises initially when confronting a feared situation, it also subsides within a few minutes, but can last up to 75 minutes.

• When you put your first step into action, stay in the situation until your anxiety has lessened.

• Monitor your anxiety to see how it starts to decrease the longer you stay in the situation.

• Remain until you no longer feel anxious before ending the task.

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Practise this step until it no longer causes anxiety.Then (and only then) move on to the next step.

6. Put the first step into action.

7. Move through each step until you can manage the feared situation.

NOTE: You might keep a record of which steps work best for you in future use.

IMPORTANT

Exposure Therapy will not work if you are intoxicated or taking sedatives such as Valium or sleeping tablets.

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Tips for succeeding with Gradual (graded) Exposure

• Begin with an achievable step.

• Don’t make your steps too easy or they will probably be unrewarding. Don’t make your steps too hard or you will probably fail and become discouraged.Aim for regular and gradual progress.

• Move on to the next step only once the present step has been genuinely mastered. Since some steps are more dif cult, at times progress may seem slow. Be patient with yourself and the process. Better to go slowly, than lose con dence and motivation by being abruptly set back by attempting too much.

• If the increase in dif culty of your steps turns out to be too high, put in some intermediate steps to make progress more manageable.

• Be prepared for setbacks. If a setback does occur, simply return to a previous step, and assess whether or not an intermediate step needs to be inserted. Don’t be discouraged – setbacks do occur, because the whole process, no matter how well thought through, may need to be altered once actually ‘put to the test.’

• Try to become conscious of your thoughts in approaching each step (particularly what you say to yourself in your head).

–  When you can identify exaggerated fears, try to replace them with more realistic thoughts about what is more likely to happen.

–  It can be helpful to write down your thoughts and ‘self- talk’ (preferably as soon as they occur), to challenge how rational they are.

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Thoughts and self-talk

How exaggerated are these? How rational?

What would be a more rational and helpful way of thinking about the situation?

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Reducing Alcohol and Caffeine Consumption

The problem with alcohol and anxiety

It is common for anxious people to ‘settle the nerves’ or to cover over their fears using alcohol. There are several problems with this:

• Alcohol becomes a substitute for developing con dence.

• Dependence can quickly (but often unknowingly) occur, with alcohol being used for anxiety control in more and
more situations.

• Usual coping strategies (even if only partially effective)
become neglected and even less effective when alcohol is
used as a substitute.

• Alcohol can negatively affect the quality of sleep, and
interferes with the effects of medication prescribed for anxiety.
Strategies for moderating alcohol consumption

• Try to avoid drinking at home alone – especially when you are feeling down or anxious.

• Try limiting your drinking to the evening meal time.

• Drink low-alcohol beers and mixes.

• Drink slowly (limit yourself to 2 standard drinks each day).

• Think ahead (and creatively) about how to avoid drinking
excessively in situations (like the pub or social gatherings)
where there is pressure to do so.

• Plan to have 2 alcohol-free days each week. Try to choose
days when it is easiest to do so, like when an activity is planned for the evening that may be a useful distraction.

  

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NUMBER OF STANDARD DRINKS – BEER

        

1.1

285ml
Full Strength 4.8% Alc. Vol

0.8

285ml Mid Strength 3.5% Alc. Vol

0.6

285ml Low Strength 2.7% Alc. Vol

1.6

425ml
Full Strength 4.8% Alc. Vol

1.2

425ml Mid Strength 3.5% Alc. Vol

34

24 x 375ml

Full Strength 4.8% Alc. Vol

0.9

425ml Low Strength 2.7% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

1.4

375ml
Full Strength 4.8% Alc. Vol

24

1

375ml Mid Strength 3.5% Alc. Vol

0.8

375ml Low Strength 2.7% Alc. Vol

     

1.4 1 0.8

19

24 x 375ml Low Strength 2.7% Alc. Vol

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

• Decide how much alcohol you will permit yourself to drink; measure it out, and only allow yourself that amount.

• Always try to stay within the Australian Alcohol Guidelines.
For Men and Women
over a lifetime:
If you drink no more than 2 standard drinks a day, you reduce the lifetime risk of harming yourself from alcohol-related disease or injury.
on a single occasion: Having no more than 4 standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.

NUMBER OF STANDARD DRINKS – WINE

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Red Wine 13.5% Alc. Vol

82

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

ANXIETY

1.4 1 0.8 34 24 19

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

24 x 375ml

Full Strength 4.8% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

24 x 375ml Low Strength 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE

      

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Red Wine 13.5% Alc. Vol

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

      

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

       

1

30ml High Strength Spirit Nip 40% Alc. Vol

1

250ml Full Strength Pre-mix Spirits 5% Alc. Vol

22

700ml High Strength Bottle of Spirits 40% Alc. Vol

1.2

300ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.1

275ml Full Strength RTD* 5% Alc. Vol

1.5

375ml Full Strength Pre-mix Spirits 5% Alc. Vol

1.2

330ml Full Strength RTD* 5% Alc. Vol

1.7

440ml Full Strength Pre-mix Spirits 5% Alc. Vol

2.6

660ml Full Strength RTD* 5% Alc. Vol

1.4 – 1.9

250ml High Strength Pre-mix Spirits

1.5

275ml High Strength RTD* 7% Alc. Vol

1.6

300ml High Strength Pre-mix Spirits

1.8

330ml High Strength RTD* 7% Alc. Vol

2.1

375ml High Strength Pre-mix Spirits 7% Alc. Vol

3.6

660ml High Strength RTD* 7% Alc. Vol

2.4

440ml High Strength Pre-mix Spirits 7% Alc. Vol

       

7% – 10% Alc. Vol 7% Alc. Vol

* Ready-to-Drink

For more information see chapter on Alcohol, page 225

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Men Women

1 in 100

 

11 10 9 8 7 6 5 4 3 2 1 0

1 2 3 4 5 6 7 8 9 10 Standard drinks

lifetime risk of death from alcohol-related disease per 100 drinkers, by number

               

figure 5

Lifetime risk of death from alcohol-related disease per 100 drinkers, by number of

of standard drinks per occasion, australia 2002

standard drinks per occasion, Australia 2002

Source: Rehm et al (2008)

For people who regularly drink 2 standard drinks per day, the lifetime risk of

death from an alcohol-related disease is about 0.4 in 100 people with that

drinking pattern. Above that level, the risk increases with the number of drinks

for people who regularly drink two standard drinks per day, the lifetime risk of death from

per day, and is above 1 in 100 at 3 drinks per day. The risk increases more sharply

an alcohol-related disease is about 0.4 in 100 people with that drinking pattern. above that

for women than for men.

level, the risk increases with the number of drinks per day, and is above 1 in 100 at three

Source: National Health and Medical Research Council Australian Guidelines to Reduce Health Risks

drinks per day. the risk increases more sharply for women than for men.

from Drinking Alcohol, Canberra: Commonwealth of Australia, 2009.

The problem with caffeine and anxiety

alcohol-related injury

Caffeine is a substance that is derived from plants or is produced

sByanstihseatincdallqyu, anlidtyisoaf nthaeddeivtidvenincea number of food products and

over-the-counter medications such as pain relievers, appetite

Lifetime risk of death from alcohol-related injury

suppressants, and cold medicines. Most commonly, it is known

A modelled analysis (Rehm et al 2008) was used to determine the

to be an ingredient in tea, coffee, chocolate, cocoa, colas, and so

accumulated lifetime risk of death from injury categories for which alcohol

called ‘energy-boosting’ beverages.

has an accepted causal effect (based on established epidemiological data:

English et al 1995; Rothman & Greenland 1998). Lifetime risk was calculated

Tea and coffee are seen by most people merely as beverages,

for an increasing number of drinks per occasion and for various numbers of

drinking occasions over a lifetime. Alcohol-attributable injury deaths per

however they do contain caffeine.

drinking occasion, and lifetime risk, were calculated using four main steps:7

• calculation of overall gender- and age-speci c risk of fatal injury per day

Because caffeine is a central nervous system stimulant, in

for each category of injury without the impact of alcohol (ie baseline risk)

anxious people it can worsen symptoms of anxiety considerably.

Consequently, it has been named in diagnoses such as caffeine-

related anxiety, and caffeine-related sleep disorder (because of its 7 Details of the modelling are given in Appendix A5.

association with insomnia).

84

national health and medical research council |

ANXIETY

Lifetime risk per 100 drinkers

People with an anxiety problem would do well to eliminate caffeine from their diet – or at least reduce intake to a nominal amount. For tea and coffee drinkers, it is now possible to purchase these products in caffeine-reduced and decaffeinated forms. For people accustomed to a high caffeine intake, it is advisable to reduce consumption gradually to minimise potential withdrawal effects.

national Help/Information Lines

• beyondblue info line: 1300 22 4636 ( local call cost)

• Lifeline: 13 11 14

• Kids Help Line: 1800 55 1800

• MensLine Australia: 1300 78 99 78

• Australian Psychological Society Referral Line: 1800 333 497

• SANE Australia: 1800 18 7263 (national)

• Suicide Call Back Service: 1300 659 467
See Key Services and Resources on pages 302 to 319 for state and territory contacts.

For more information, see Fact sheet 9 Reducing alcohol and other drugs at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

85

ANXIETY

DistuDrbepinrgeTsshionughts

87

Disturbing Thoughts

Disturbing thoughts are danger signs that should not be ignored.

Tickþthe signs that are familiar:

rThinking things are hopeless and won’t change in the future rThinking or saying to yourself:

− life isn’t worth living, or
− people would be better off without me, or
− nothing is ever going to get better, what’s the point of going on, or
− there will be no end to the mental/emotional pain I’m feeling, or
− my relationship/marriage is in such trouble I just can’t bear it; I don’t want to go on….what’s the point?

r Thoughts about death and dying, and how people would cope without you

rYou have had thoughts about:
− what you might do to yourself to end your life
− when and where you would do it
− what you might use to end your life
− who you would put in your will, and the instructions you would leave for people, or the note you would write, for after your death.

rThoughts about hurting others
rThoughts about harming or mutilating yourself
rBeing very suspicious about other people’s intentions towards

you
r Thoughts that you are being persecuted, taken advantage of or

wronged in some way
rBeing preoccupied with intrusive thoughts or perceptions that

are important to you, but which others don’t understand or accept the importance of.

  

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88

Feelings that often accompany disturbing thoughts:

rFeeling an overwhelming sense of failure in life
rFeelings of emotional/mental pain that are almost unbearable

and seem to get no better
rFeeling hopeless and helpless much of the time
r Feeling sad, miserable and/or depressed for days at a time rFeeling unsafe

Behaviours that sometimes accompany disturbing thoughts:

r Becoming withdrawn, avoiding people and social events rIncreasing use of alcohol or other drugs to try to cover

feelings of mental pain and hopelessness
rBecoming secretive about your thoughts and feelings of

hopelessness and helplessness
r Being careless, taking needless risks, acting dangerously, or

putting yourself in harm’s way
Thoughts, feelings and behaviours of this kind need to be taken

very seriously. Do not ignore them.
.TAKE URGEnT ACTIon.

Arrange to speak to a doctor OR

Phone a 24-HoUR MEnTAL HEALTH EMERGEnCY LInE

national

Lifeline: 13 11 14
Suicide Call Back Service: 1300 659 467

State and Territory
ACT:
Crisis Assessment and Treatment Team: 1800 629 354 nSW: Salvo Suicide Prevention & Crisis Line: Metro

02 9331 2000
Salvo Suicide Prevention & Crisis Line: Rural 1300 363 622 Suicide Prevention and Support: 1300 133 911

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DISTURBING THOUGHTS

nT: Mental Health on Call Team:Top End (08) 8999 4988 Mental Health on Call Team: Central Australia
(08) 8951 7777

QLD: Salvo Crisis Counselling Service: Metro 07 3831 9016 Salvo Crisis Counselling Service: Rural 1300 363 622

SA: Mental Health Assessment and Crisis Intervention Service: 13 14 65

TAS: Mental Health Services Helpline: 1800 332 388 VIC: Mental Health Advice Line: 1300 280 737

SuicideLine: 1300 651 251

WA: Mental Health Emergency Response Line: Metro 1300 555 788

Rural Link: Rural 1800 552 002 Samaritans Crisis Line: 1800 198 313

nATIonAL HELP/InFoRMATIon LInES

beyondblue info line: 1300 22 4636
Lifeline: 13 11 14
MensLine Australia: 1300 78 9978
Kids Helpline: 1800 55 1800
Australian Psychological Society Referral Line: 1800 333 497 SANE Australia: 1800 18 7263

 

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90

Some things to consider if you are experiencing suicidal thoughts

• No matter how bad your situation, no matter how overwhelming your mental/emotional pain, there is always a better option than considering suicide or self-harm – but it may not have occurred to you. Speak to a doctor (and other help can follow). Or phone a 24 hour Mental Health Crisis line.

• When people kill themselves, it seriously affects their family and friends. Feeling “They’d be better off without me” doesn’t cancel out the fact that they would be greatly damaged – perhaps for life.

• Promise yourself (and someone else) that you will get help, that you will do it now, and you will not give up until you get it.

I promise, for my sake and for the sake of others, that I will get help NOW

Signed………………………………………………………………………………………

• Suicidal thinking is often driven by depression. 90% of older people who attempt suicide have a mental illness – usually undiagnosed depression. Remember, depression is an illness, not a chosen state of mind. Risk of actual suicide increases without treatment.

• Break your silence and isolation: get help NOW.

• Feelings of hopelessness, helplessness, and overwhelming mental/emotional pain can be turned around with appropriate treatment.

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More powerful than all problems is the courage to deal with them.

• If you think a particular problem has brought you to this point, try using Structured Problem-Solving (included in this section).This may ‘take some pressure off’. However, still speak to a doctor about your mental state.

• Who are the people who really matter to you? Think about why they do care, and the good things that have happened between you.
REMEMBER
Things can feel very different and look very different; energy, motivation, problem-solving ability, and hope for the future can be restored if you act with courage and speak to a doctor or phone a Mental Health Crisis Line.

 

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DISTURBING THOUGHTS

To help someone else

IMPORTANT

• First and foremost recognise that you are not responsible for someone else’s suicidal behaviour. You have no control over the person’s will. If the person chooses to act in a self-harming or destructive way, he/she has chosen to do so; he/she is responsible.

• Asking a person if he/she has suicidal thoughts will not encourage the person to act on these thoughts, but will signal genuine concern and an avenue of hope.

• People who are experiencing suicidal thoughts, whether depressed or not, may not be easy to help.They may have become secretive and evasive, or may be so depressed or troubled that they view everything as pointless except ending how they feel. Persevere anyway.
Useful tips for helping someone who may be suicidal

• Think about the best way to approach the person – given what you know about his/her personality and temperament.

• Let the person know that you are seriously concerned. Suggest that he/she might see a doctor immediately or speak to a health professional recommended by a doctor − or ring a 24 hour Mental Health Crisis Line. Help the person to make the appointment or phone call. Offer to take or go with him/her to receive assistance.

• If you think the person won’t listen to you, then consider who he/she usually con des in, feels comfortable with and/ or trusts. Maybe this nominated person could make the approach and encourage the person who may be depressed to seek assistance.

 

The most important aim is to keep the person safe.

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DISTURBING THOUGHTS

• Provide the person with a 24 hour crisis line number (see page 89 and 90).Try to get the person to put it where it won’t be lost and will be accessible.

• Enlist the help of relatives or friends to keep a watchful eye on the person, to break his/her isolation, and to provide extra safety.

• Maybe you can help the person to work through a major problem rationally, resolve a relationship con ict, or get a new perspective on things (see Structured Problem-Solving on page 96).

• Encourage the person to think about what is valuable, worthwhile and precious in his/her life. As well, encourage the person to recognise who depends on and values him/ her.

• Be as determined and resourceful as you can in nding a way to get the person to a doctor or appropriate health professional (or to seek help by phoning a Mental Health Crisis Line).

• Emphasise that mental/emotional pain, depression, low energy, and feelings of hopelessness and helplessness can be quickly turned around with appropriate treatment from a doctor. Left untreated, the person’s mental state may deteriorate. The risk of acting on suicidal thoughts and feelings increases without treatment.

• Try to get agreement on a no Harm/Seek Help promise (an example is included on page 95).

• Be determined, but respectful.

• Listen to the person carefully.

• Think safety.

• Avoid being overdramatic; be calm and thoughtful.

• Remind yourself that you are not responsible for someone else’s suicidal behaviour.

 

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94

no Harm – Seek Help PRoMISE

I give my word that I will not harm myself or put myself in danger and that I will seek help until I get help to deal with what is happening to me.

Signed: ………………………………………………………………….. Witnessed: ……………………………………………………………. Dated:……………………………………………………………………

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DISTURBING THOUGHTS

Structured Problem-Solving

Some problems can feel absolutely overwhelming, and impossible to deal with.

Structured problem-solving is a method designed to help you feel in control of a problem, and to nd a way through it.

The key elements of this method include:

• identifying and ‘pinning down’ the problems that have contributed to you feeling overwhelmed

• thinking clearly and constructively about problems

• ‘taking stock’ of how you’ve coped in the past: your
personal strengths and the support and resources available
to you

• providing a sound basis for important decision-making.

  

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96

Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly − including good and not so good options); write them down:

 

STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

 

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DISTURBING THOUGHTS

a. b.

c. d.

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________ ____________________________________________________

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DISTURBING THOUGHTS

Some Facts about Suicide

Most people who die by suicide are affected by a mental disorder. Ninety per cent of older people who attempt or die by suicide have a mental disorder that is often undiagnosed and untreated. In most cases, these people have been experiencing depression.

Though depression is the most common mental disorder associated with suicide, some suicides are impulsive; many who attempt to end their lives are not so much motivated by a desire for death, but to escape the mental/emotional pain and anguish they are experiencing. This is important to understand, because when someone is on a path to suicide, it is often possible to intervene in a way that gives them the resources to cope with or overcome their pain and dif culties without resorting to self- harm.

The of cial number of recorded suicides in Australia has decreased in recent years following peaks in 1997 and 1998. Despite these decreases, suicide remains a major cause of death. For example, in each of the years from 1994 to 2004 the total number of deaths from suicide was greater than the number of deaths from road accidents.

Research shows that more women deliberately self-harm and attempt suicide than men, however men in Australia are almost four times more likely than women to die from a suicide attempt.

There were 1,881 deaths from suicide registered in 2007, representing 1.4% of all deaths that year. Men of all age groups in Australia are far more likely than women to die from suicide. In 2007, the rate of suicide deaths was 13.9 per 100,000 men compared to 4 per 100,000 women.

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DISTURBING THOUGHTS

Suicide rates for men have been consistently higher than for women throughout the time Australian data has been collected.

In 2007:
77% of suicide deaths were men
21% of all male deaths under the age of 35 were by suicide.

Suicides in 2007 occurred at a rate of:

• 8.3 per 100,000 in the 15-24 age group

• 12.8 per 100,000 in the 25-34 age group

• 13.1 per 100,000 in the 35-44 age group

• 12.2 per 100,000 in the 45-54 age group

• 10.6 per 100,000 in the 55-64 age group

• 8.0 per 100,000 in the 65-74 age group

• 9.6 per 100,000 in the 75-84 age group

• 10.2 per 100,000 in the over 85 age group
Source: Australian Bureau of Statistics. (2009).
Causes of Death, Australia, Suicides 2007. ABS Catalogue No. 3303.0.
Factors that contribute to suicide risk

• Marital breakdown/relationship problems

• Bereavement

• Depression (or other mental disorders)

• Unemployment

• Financial problems – including a sudden change in nancial circumstances

• Previous suicide attempt

• High levels of stress, distress and depleted (‘run down’)
emotional and personal coping resources

• Ready access to a rearm, pills, or other means of
committing suicide

• Alcohol dependence and/or abuse

• Deliberate self-harm

• Isolation

 

DISTURBING THOUGHTS

 

100

Factors believed to diminish suicide risk

• Family connectedness

• Responsibility for children and others

• Close relationships/friendships

• A sense of meaning and purpose in life

• Personal resilience and problem-solving skills

• Being connected to a community and social activities

• Good mental health

• A preparedness to seek out early help for mental health
dif culties

• A belief that suicide is wrong

• Lack of access to guns
Major issues for men
Some of the most telling issues linked with male suicide in Australia include:

• alcohol use, marijuana or other drug dependence

• a sense of failure in life, towards family, and nancially

• family/relationship problems

• loneliness, isolation

• physical or mental illness

• unemployment and/or nancial problems

• unaddressed depression.

Most telling issues relative to age:

• A sense of failure appears most signi cant to men under 45 years of age.

• Family/relationship problems and a sense of failure appear to be signi cant factors for men aged 45-49 years.

• Physical and/or mental illness and family problems appear to be signi cant factors for men aged 60-69 years.

• Loneliness or physical illness appear to be signi cant for men aged 70 years (Hassan, 1995).

SSee section on DEPRESSIon (Page 2)

 

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102

ReDceopverersysiforonm Trauma

Information in this chapter provided in association with the Australian Centre for Posttraumatic Mental Health

103

Recovery from Trauma

Warning signs of a problem with traumatic stress

Tickþthe signs that are familiar:

r You have been through an event during which you experienced intense distressing emotions such as fear, helplessness or horror

r Intense memories/thoughts of the event keep re-occurring and are highly distressing

r You get emotionally upset when something reminds you of the event

r You have unpleasant dreams or nightmares about the event r When you think about the event, you feel sweaty, tense, your

heart races and your breathing increases

r You try to avoid activities, places, or people that remind you of the traumatic event

r You avoid thoughts, feelings or conversations that are associated with the trauma

r You are having dif culty sleeping, concentrating and/or you feel highly irritable since the event

r You feel depressed or have low motivation
r You have high levels of irritability or anger that is interfering

with your relationships
r You feel intense guilt about the event

If it has been over four weeks since the traumatic event and some or all of the above symptoms are interfering with your ability to carry out the things you usually do, such as work or study −

.TAKE ACTIon. Arrange to speak to a doctor.

  

RECOVERY FROM TRAUMA

 

104

What is a traumatic event?

A traumatic event is often de ned as an event which involves an encounter with death, or the experience of severe injury. Some traumatic events only have the potential of death or injury – that is, the event doesn’t actually result in death or severe injury, but the individual believed that it could have done.When someone says,“I thought I was going to die,” that is more important than whether or not the person was actually in danger of being killed.

Traumatic events usually result in intense emotional responses such as fear, helplessness or horror. In Australia, common traumatic experiences include disasters (such as bush res), being threatened with a weapon, being physically assaulted, being involved in a life threatening accident, sexual assault, and child abuse or neglect. Other traumatic events include things like war, kidnapping and being tortured.Witnessing these types of events happening to others, or learning about these kinds of events occurring to loved ones, may also be a traumatic experience for some people. Unfortunately, traumatic experiences are common. Around 65 per cent of Australians have experienced at least one traumatic event and many will experience more than one event.

Common reactions to trauma

Individuals who have gone through a traumatic event often experience many different emotional reactions.This is referred
to as traumatic stress and, in its milder forms, is part of a normal reaction to very frightening events. Common experiences include:

Distressing memories of the event – Distressing memories or thoughts of the event may enter your mind even when you don’t want them to.This may include images or thoughts about the event, or sensory experiences like sounds or smells. Nightmares are also common. Although memories and nightmares are distressing, they are part of the body’s natural way of coming to terms with, or getting used to, very frightening events. Re-experiencing provides you

 

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RECOVERY FROM TRAUMA

with the opportunity to try to make sense of the experience and understand what it means to you. For the majority of people, these memories usually fade over time.

• Physical symptoms – When a person is anxious, his/ her body will respond with a ‘ ght or ight’ response.This response can include shortness of breath, increased heart rate, sweating, shaking, feeling restless, muscle tension and nausea. Read the Anxiety chapter in this book (page 41) for more information on anxiety disorders.

• Avoidance – You may nd yourself avoiding activities, situations or people that remind you of your traumatic experience.

• Depression and grief – It is usual to experience sadness and grief following a traumatic experience. It is normal to feel upset and confused when you think or talk about your experience. Grieving is a process of healing − it is part of the process of coming to terms with the things you have lost.This sadness usually lifts as you start to adjust to your experience.

• Guilt – Guilt is a strong emotion that people often feel following a traumatic experience.You may feel guilty if you think you were responsible for the event or for not avoiding it. Some people feel guilt because they survived while others did not.They may feel guilty because others experienced more of the trauma than they did.

• Anger – At some stage, people usually experience anger about the traumatic experience.Anger may be directed toward yourself or toward others. It may be about the injustice of the situation, the carelessness of others or your stupidity for getting into the situation.

• Sleeping dif culties – Following a traumatic event, you might nd it dif cult to fall asleep and/or stay asleep. Nightmares and bad dreams can make sleeping dif cult. One reason sleeping is dif cult following a traumatic experience is because of increased stress levels. When we are stressed, our bodies release adrenaline and we become alert, making it almost impossible to sleep.

 

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106

Concentration and memory dif culties – Following a traumatic experience, you may notice that you are easily distracted and that your concentration is very poor.This is because your mind is preoccupied with going over and over the traumatic event, so that you have little space for anything else.

When to seek professional help

The above reactions to trauma are common and – as long as they are not too severe and they do not last too long – they
are a normal part of adjusting to a traumatic event.They can be distressing, but for most people, the reactions gradually decrease over time. These symptoms are part of the natural healing process of adjusting to a very powerful event, making sense out of what happened, and putting it into perspective.

Sometimes traumatic events can be dif cult to overcome and professional help may be required. If you tick any of the boxes below, talk to your GP:

r Continue to experience high levels of distress four or more weeks after the traumatic event

r Feel very distressed, frightened, irritable or on edge much of the time

r Find yourself avoiding situations because they remind you of the traumatic event, and this is causing you dif culties

r Are unable to carry out your normal role at home, work, or school

r Find that your distress is interfering with your important relationships such as with friends or family

r Feel hopeless, despairing and think that you can’t go on r Are thinking of harming yourself or someone else

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RECOVERY FROM TRAUMA

Signs and symptoms of Post-Traumatic Stress Disorder (PTSD)

People with PTSD often experience feelings of panic or extreme fear, which may resemble those sensations that were felt during the traumatic event. A person with PTSD has four main types of dif culties:

1. Re-living the traumatic event – through unwanted and recurring memories, often in the form of vivid images and nightmares.There may be intense emotional or physical reactions, such as sweating, heart palpitations or panic when reminded of the event.

2. Being overly alert or wound up – sleeping dif culties, irritability, lack of concentration, becoming easily startled and constantly being on the look out for signs of danger.

3. Avoiding reminders of the event – deliberately avoiding activities, places, people, thoughts or feelings associated with the event because they bring back painful memories.

4. Feeling emotionally numb – losing interest in day-to-day activities, feeling cut off and detached from friends and family, or feeling emotionally at and numb.

These symptoms usually lead to signi cant distress and interfere with the person’s ability to work and study, as well as his/her social relationships. It’s not unusual for people with PTSD to experience other mental health problems at the same time. These additional problems, most commonly depression, anxiety and alcohol or drug use, are more likely to occur if PTSD has persisted for a long time.

  

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108

Signs and symptoms of Acute Stress Disorder (ASD)

ASD is very similar to PTSD. The main difference is the length of time that problems remain after the traumatic event. ASD
is diagnosed when serious problems occur in the rst month after a traumatic incident. If problems continue to impact on a person’s life for longer than one month, PTSD may be diagnosed. People with ASD are at high risk of developing PTSD. For more information on ASD visit http://www.acpmh.edu.au

How to help yourself

Adjusting to, and recovering from a traumatic experience takes time.You will have good days where you feel like you are moving forward to recovery and other days when you will feel like you are going backwards.While the process of recovery may be long and painful, many people are able to use the experience to grow. People often feel that they come out of the traumatic experience with a stronger belief in themselves, with improved social relationships and bene ts in personal growth and life priorities. You may not feel like this at the moment, but it is worth remembering this as you progress down the road of recovery.

 

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RECOVERY FROM TRAUMA

Helpful Strategies to Recover from a Traumatic Event

Talking about the event

Although you might want to just forget about what you’ve been through, talking about it is very important. Many people avoid talking about their experience in depth because they feel they will be overwhelmed with distress. However, talking about your experience is the way to begin your recovery process.

Talking (or writing) about the trauma helps your recovery in a number of different ways. Firstly, it helps you make sense of the experience.You can ll in bits of information that are missing. It helps you to see your experience clearly and may help you see
it from different perspectives. Other people’s opinions can also be useful to help you take a different perspective. Secondly, the more you tell your story, the more you get used to it and the less distressing it becomes. Like when you rst learn to drive, you may feel anxious, but the more you do it, the less anxious you feel.This will happen with telling your story – it is very dif cult at rst, but it will get easier.

   

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110

Talking about the event − Strategies

• Choose someone you trust and whom you think can cope with your story. Some trauma experiences are
so horri c and distressing that it is better to tell a professional person such as a psychologist, psychiatrist or other trained mental health professional.Your GP can help you nd someone suitable.

• Start gradually by just outlining what happened.

• As this becomes easier, ll in some more detail.

• Finally, tell your story with as much detail as you can. This will include what happened (including what you saw, heard, smelt, etc.) as well as how you reacted (what you did as well as what you were thinking, feeling, etc). Remember, each time you tell your story, the easier it becomes.

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RECOVERY FROM TRAUMA

Writing your story − Strategies

• Writing can also be useful in assisting your recovery, especially if you do not have someone with whom you feel comfortable talking about what happened.

• Start at the beginning; write down what happened, how you were feeling at the time, what things were going through your head during the experience. Include as much detail as you can.

• Read through it to make sure you haven’t missed anything.You will probably feel quite sad and/or anxious when writing – these feelings are normal and helpful.

• Over the next couple of days, read through your story and add in bits you may have missed out. Reading the story helps you adjust to what you’ve been though. If it is painful to read through your story, remember that each time you read through it, it will be become easier.

• Sometimes during this process you might nd yourself getting ‘stuck’ by a particular thought (like “It was all my fault” or “I’ll never be safe again”). Usually these thoughts will change as you repeat the writing and come to see what happened from a different perspective. If they don’t, it is worth considering some professional help to get you over that hurdle.

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112

Dealing with reactions to a traumatic event

Dealing with anxiety

• Take up relaxation or meditation classes (see page 52).

• Schedule in quiet time, where you take time out for yourself to do something enjoyable like taking a bath, reading a book, listening to music.

• Do other things to look after yourself such as eat well, exercise regularly, rest regularly, and decrease your use of alcohol and cigarettes.

Dealing with avoidance (See Gradual Exposure section on page 74).

• Talking or writing about what happened is a good way to stop avoiding the memories and start your recovery.

• When you feel ready, try
to visit the place where the traumatic event happened or look at photos taken of the event if relevant.

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Dealing with grief and depression

• Think about all that you have lost as a consequence of
this event. It may be friends, family or possessions; it may be something about your physical body, or it may be something else about you like your independence, health, or a sense of safety.

• Talk or write about what you have lost, and how it feels to have lost these things.

• Think about how you can rebuild these things. For example, to rebuild your sense of control – try to make as many day-to-day decisions
as possible for yourself.This will increase your feeling of control over your life.

• Think about whether any good things have come out of this experience; the things you have learnt about yourself and others, about new directions, or new priorities.

• Read the Depression chapter of this book, especially the section Activity Planning on page 24.The Grief chapter of this book deals with normal grieving and complicated grief (see page 267).

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114

Dealing with anger

• Read the chapter on Anger in this book (page 159) for some helpful advice.

Dealing with guilt

• Often guilt arises when we take on too much responsibility for the traumatic event.

• Think about how responsible you were for the situation.

• Make a list of all the people and aspects of the situation that contributed to the event.Think about what percentage each contributed to the situation. For example, you may feel very responsible for your car accident, however when you do this exercise, you’ll realise that lots of other things (such as weather, road and traf c conditions, other drivers) also contributed to the accident. This exercise helps you put your behaviour in perspective, and helps you make sense of the situation.

Dealing with sleep disturbance

• The Insomnia chapter of this book (page 118) has some helpful hints about dealing with sleeping problems.

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Dealing with concentration and memory problems

• Help your memory by carrying around a small note pad and writing down things you want to remember.

• To remind yourself of appointments or other things, place notes in strategic places (like stuck to your mirror).

• Make allowances for your poor concentration − give yourself more time than usual to carry out a task.Try not
to give yourself a hard time about forgetting things or not concentrating.

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116

Referral information

There are services that can help you adjust to your trauma.

Speak to your local doctor and tell him/her of your dif culties. The doctor can refer you to a psychologist, psychiatrist or other mental health practitioner.

Your Community Health Service or Community Mental Health Clinic may also offer some counselling services – check your local phone book for contact details.

The Australian Psychological Society Referral Line –
1800 333 497 – can give you the names of psychologists who deal with traumatic stress in your area.We recommend you ask for a clinical psychologist who uses Cognitive Behaviour Therapy (CBT) (see page 6).

And nally, remember, things will get better. After a traumatic experience, it is sometimes hard to see any light at the end of the tunnel. However, don’t lose sight of the fact that it will get easier – even if that’s hard to believe at the moment. Having this knowledge is important in pushing on with your recovery.

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Insomnia

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Warning Signs of a problem with INSOMNIA

Tickþthe signs that are familiar

qDif culty falling asleep
qDif culty staying asleep
qWaking up too early at the end of the sleep period qDif culty getting back to sleep after waking
q Feeling worried, annoyed, frustrated, anxious, or angry at

bedtime or while lying in bed trying to go to sleep
qRacing thoughts when trying to go to sleep or when waking in

the night
qFeeling physically or mentally tired during the day
qYour sleep has been disturbed for 3 or more days per week

for at least a month
qSleep disturbance is causing you signi cant personal distress

or interferes with your social life or ability to work qPoor quality of sleep (not waking feeling refreshed despite

having been asleep for a reasonable period of time) qYou’re very concerned about your lack of sleep (most of the

time), and the consequences of this lack of sleep
qSpending excessive time in bed and experiencing sleep broken

by frequent awakenings
q Falling asleep early each evening (before 9pm), waking very

early and being unable to return to sleep

If some of these signs are familiar and poor sleep is affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor

  

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Why speak to a doctor?

Restoring a normal pattern of sleep usually requires little more than the use of some simple guidelines and strategies. But because there are many factors that can cause or contribute to insomnia, requiring medical diagnosis, treatment, or referral, it is important to speak to a doctor. These include:

• medical disorders associated with insomnia

• mental disorders associated with insomnia

• prescription medications

• use of non-prescription drugs and alcohol

• sleep disorders associated with malfunctioning body organs.

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About Insomnia

Sleep problems are one of the most common complaints people make when presenting to doctors in general practice.

Twenty to twenty- ve per cent of Australians report suffering from some form of lasting insomnia at some time in their lives. Up to 12% have long-term (chronic) dif culty either going to sleep or maintaining sleep.

Common complaints of people with insomnia are:

• dif culty falling asleep

• dif culty staying asleep

• waking up early at the end of the sleep period

• feeling anxious, irritable, worried or depressed – especially at bedtime

• racing thoughts when waiting to go to sleep or when waking up in the night

• feeling physically or mentally tired during the day. What are the effects of insomnia?
Sleep is a natural process that allows the body and brain time to recover from daily activity. During sleep, the body makes chemicals which help it grow and repair, and the immune system becomes more active to ght infection and illness.
Sleep is also important for emotional balance and a healthy mood state. It is also thought that sleep is a time when memories, experiences, and skills are sorted and stored. But what about when sleep is disturbed, when people fail to get enough sleep, or their quality of sleep is poor?
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Some of the consequences of insomnia

• Fatigue (due to tiredness) is involved in approximately 1 in 6 fatal road accidents in Australia.

• An older person with insomnia has 4 times the risk of having a fall and suffering a major injury.

• Tiredness and fatigue are responsible for 52.5% of work- related accidents and almost 29% of accidents around the home. Nearly 10% of people with chronic insomnia experience serious accident or injury.

• Staying awake for 17 hours decreases performance, the same as a blood alcohol level of 0.05%.

• After 5 nights of poor sleep, 3 drinks have the same effect on the body as 6 would when the person is well rested.

• People experiencing insomnia are 25% more likely to miss work.

• Studies of people with insomnia show the disorder impairs concentration, memory, and the ability to accomplish daily tasks, and affects interpersonal relationships.
What causes insomnia?
Insomnia commonly begins during times of increased life
stress. Most people at some stage in their lives experience sleeplessness due to lying awake at night thinking about personal problems, work, or their nances.This sleep dif culty is only
a temporary problem that will likely resolve within a few days
or weeks. Sometimes though, especially if the stressful issue is major and a person’s ability to function is signi cantly affected
by sleeplessness, he/she will also become preoccupied with the inability to get to sleep.The effect is a vicious cycle of anxiety and worry about not sleeping, feeding into and worsening the problem of sleeplessness itself. In this way, a temporary problem of sleeplessness can develop into insomnia.

 

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Sleeplessness

Anxiety about inability to sleep

Insomnia

      

Though times of increased stress are a common beginning for insomnia, there are actually many factors that can cause or contribute to it such as:

• ageing

• lifestyle commitments

• physical disorders

• mental disorders

• prescription medication

• non-prescription drugs and alcohol.

 

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What about using medication?

Medication may be prescribed for a short period of time (3 to 5 days). However, the preferred approach to overcome sleep dif culties is NOT to use medication.

The use of sleeping pills (sedative hypnotics) for any length
of time can cause more problems than it solves: dependence, addiction, returning symptoms, side-effects and for older people in particular, an increased risk of falls.

Problems associated with Sleep Medication

  

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Self-help Sleep Guidelines and Therapies

Individual differences in the need for sleep

People differ in the amount of sleep they need. Some people appear to need 9 to 10 hours sleep each night, whereas others can wake refreshed and function well during the day on 4 to
5 hours sleep each night. As people get older, they generally require less sleep. Few people in their sixties need as much sleep as when they were in their thirties. Teenagers tend to need as much sleep as small children – around 10 hours per night.

You are the best person to judge whether you have a problem with sleep. You may feel ne and function well even though you don’t get a lot of sleep. However, if this is not the case, and your life is being adversely affected by insomnia, there are some very effective measures you can take to establish a better pattern of sleep.

Better Sleep Guidelines

To establish a better pattern of sleep, often all that is necessary is to practise sleep promoting behaviours during the day, in the evening, at bedtime, and during the night.

During the day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns. Avoid exercise late in the evening as this may make getting to sleep more dif cult.

• Set aside time for problem-solving and decision-making during the day to avoid worry or anxiety at night. (See Structured Problem-Solving included in this section.)

• Avoid napping during the day – go to bed and get up at regular times.
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During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your diary to be dealt with tomorrow.

• Light exercise early in the evening may help sleep; exercise late in the evening may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep, and keep your intake moderate (2 standard drinks each day). Have 1 or 2 alcohol- free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or warm.

• Ensure that your bedroom is dark and that the morning light does not lter in (except if you have a tendency to oversleep, in which case it may be helpful to let the morning light into the room).

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack might help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation on page 134). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t read, watch TV, or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual
activity).

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For more information, see Fact sheet 7 Sleeping well at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready.
Enjoy relaxing your mind and body, even if you don’t at rst fall asleep.
During the night

• If you wake up too early in the night don’t lie awake for more than 30 minutes. Instead of just being awake or worrying, get out of bed and do something that is distracting yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, have earplugs handy to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.
Taking note of your sleep pattern
Before looking at the role or relevance of self-help sleep therapies, it is best to be clear about the factors or patterns evident in your sleep over a 2 week period. There may be some features of your sleep dif culty of which you are unaware.
You may be able to simply recall enough of this information to complete a sleep diary. If not, then monitor what happens for the next 2 weeks. A solution cannot be matched to a problem until the problem is clearly de ned.

 

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DAY

Time of getting to bed

Time taken to fall asleep

no. times woke up

Time spent awake during night

Sleep Diary

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Time of waking up in morning

Time of getting up

Daytime naps

Exercise (type and duration)

Alcohol, caffeine, drugs

Significant events today

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Insomnia is affecting your ability to enjoy life.
You worry about not sleeping or how you’ll cope the next day.

Better Sleep Guidelines should suffice

You don’t seem to be able to relax in bed. Your mind races, you feel tense, you toss and turn a lot.

Relaxation Therapy

Going to bed has become associated with not sleeping.
You get worried, anxious and frustrated.

You feel less sleepy after turning out the lights than before you went to bed.

Stimulus Control Therapy

Choosing a self-help therapy

Sleep pattern Sleep Therapy

    

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Sleep pattern Sleep Therapy

You have been spending an excessive amount of time in bed (9 or more hours).

You do this in the hope of trying to catch up on lost sleep

Bedtime Restriction Therapy

You don’t get to sleep until the early hours of the morning.
You have difficulty getting up early each morning even with an alarm.

Bright Light Therapy (Morning)

  

You tend to fall asleep before 9pm each night. You wake too early and can’t get back to sleep.

Bright Light Therapy (Evening)

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Relaxation Therapy

There are many different relaxation methods including: meditation, self-hypnosis, mental imagery, yoga, special relaxation music. These (and many others) are readily available from book stores, libraries, and on the internet.

Progressive Muscle Relaxation

A method of relaxation with proven effectiveness which relieves muscle tension and anxiety is progressive muscle relaxation. This involves tensing and then relaxing muscles in a step-by-step sequence. The two main principles of this technique include:

1. Tensing muscle groups (one at a time) to become aware of the feeling of tension.

2. Relaxing the muscles and feeling the tension in them subside – as if owing out of the body.

  

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Progressive Muscle Relaxation

• You will need about 15 minutes for this relaxation exercise.

• Find a quiet place where you won’t be interrupted.

• Sit in a comfortable straight backed chair, with your feet
at on the oor.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Tense each of the following muscle groups for 5 seconds, then relax them completely for 15-20 seconds (pay particular attention to the different sensations of tension and relaxation):

1. Curl both your sts and tighten your biceps and forearms (as if lifting weights). Relax.

2. Wrinkle up your forehead; tighten the muscles in your face causing your face to wrinkle; purse your lips and press your tongue against the roof of your mouth; hunch your shoulders. Relax.

3. Arch your back as you take a deep breath into your chest. Relax.

4. Taking a deep breath, gently push out your stomach. Relax.

5. Pull your feet and toes backwards tightening your shins. Relax.

6. Curl your toes at the same time as tightening your calves, thighs and buttocks. Relax.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Now resume normal activities in a calm and peaceful manner.

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Tips and cautions on the use of progressive muscle relaxation

• Be patient with yourself and this technique.You may only experience partial success at rst. In time, it should be possible for you to relax your whole body quickly and successfully. Practise is the key.

• Be careful when you are tensing your neck and back. Excessive tightening could result in muscle or spinal damage. Over-tightening your toes or feet could result in muscle cramping.

• To achieve the best results with this technique, it is important to let go of the tension in a group of muscles you have tensed instantly. Releasing tension slowly may seem to relax muscles, when in fact it may just sustain tension.When you release muscle tension, do it instantly and let the muscles suddenly become limp.

  

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Stimulus Control Therapy

Not being able to get to sleep may be because a negative association or link has developed between going to bed and not being able to sleep. It may be that the original reason for not being able to sleep (for example, a stressful event) has resolved, but dif culty getting to sleep continues.

Your bedtime routine, your bed and bedroom, even turning out the light, may have become the stimulus – the thing that triggers (psychologically) a negative reaction of anxiety, frustration, or worry. So the process of going to bed sets off a reaction that prevents you getting to sleep. This is called conditioned insomnia.

To turn this around, what is needed is to make your bed and bedroom a positive (rather than a negative) trigger for sleep.

Here is what to do:
Step 1
Only use your bedroom for sleep or sexual activity (no

eating,smoking,TV,arguing,reading).

Step 2 Get up and out of bed at the same time each morning. Do this even on weekends or if you have had a late night.

Step 3 Don’t go to bed at night until you feel sleepy.

Step 4 When you have gone to bed and turned the light out, if you don’t get to sleep within about 15 minutes, get up again and do something distracting but relaxing. When you feel sleepy go back to bed. Don’t try too hard to fall asleep; just relax.

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Step 5 If you can’t get to sleep quickly, repeat step 4. Repeat this step as often as necessary until you can fall asleep quickly.

Step 6 Resist napping during the day, even after a night of poor sleep.

Step 7 Follow these steps for several weeks, until a better pattern of sleep is established.

IMPORTANT

• Following the steps of Stimulus Control Therapy may take perseverance, and may result in less sleep than usual in the rst few days. However, the build-up of tiredness that will likely result, will eventually help you fall asleep more quickly. After a while a new positive association between bed, bedroom, bedtime routine, and sleep will be established,
so that these things trigger sleep rather than anxious wakefulness.

• Information in Better Sleep Guidelines (page 126) may also help you improve your sleep.

 

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Bedtime Restriction Therapy

People who have a problem with insomnia can end up spending more and more time in bed in an attempt to catch up on lost sleep.This actually makes the problem worse:

• Negative feelings can become associated with being in bed. Such feelings increase alertness, making it more dif cult to fall back to sleep when waking in the night; which in turn can cause daytime exhaustion, which likely occurs because of the constant physical tension brought about by sleep anxiety.

• Sleep spread across such a long time in bed becomes shallow and fragmented.
The principle behind Bedtime Restriction Therapy is to signi cantly decrease the time spent in bed and to consolidate sleep into that time. This helps to improve sleep quality and
a person’s sense of control over sleep. Put another way, this therapy aims to decrease shallow unrefreshing sleep, and increase (within a much shorter sleep period) the amount of deep, quality, refreshing sleep. The effect should also be to diminish sleep anxiety and night time awakening, and increase daytime energy.
Here is what to do:
Step 1
Use the Sleep Diary (included in this section) to record
your total daily sleep time over 2 weeks.
Step 2 Excluding the times you spent lying awake in bed, calculate the average amount of sleep you’ve had each night.

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Step 3 Step 4

Step 5

Choose a wake-up time that suits your personal circumstances and stick to it every day of the week.

Now, set a regular bedtime. Simply calculate back from your set wake-up time by the average number of hours of nightly sleep you’ve been getting. For example if you’ve been getting 5 hours of sleep each night, and you’ve set your wake-up time at 6.30am, then your regular bedtime will need to be set at 1.30am.

After a few nights, if you have fallen asleep sooner and have slept better than before, increase your bedtime
by 30 minutes – which means going to bed 30 minutes earlier. If you nd you are awake for more than 40 minutes each night (including the time it takes to get to sleep and time spent awake in the night) do not extend your time in bed.

After a few more nights, if you are still falling asleep easily and remaining asleep, increase your bedtime by a further 30 minutes.

Repeat step 6 until you get to the point of no longer falling asleep quickly, and no longer sleeping well through the night (i.e. when your total being-awake time exceeds 40 minutes). At this point you are spending too long in bed, and need to reduce it by 30 minutes to the previous bedtime.

Step 6

Step 7

 

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IMPORTANT

• Once you have worked out your ideal bedtime, stick to it.

• At rst, you will probably feel quite tired and maybe even irritable until you adapt to a new and much shorter sleep schedule.

• If you feel sleepier than usual when you wake up in the morning, or during the day, don’t be tempted to nap. Make yourself persevere, because some pressure of insuf cient sleep early in this process will help your improvement.
Bedtime Restriction Schedule

BEGInnInG

Average total sleep per night ………….. Hours

My wake up time will be …………………………..

My bedtime will be: …………………………..

My bedtime will be: ……………..

My bedtime will be: ……………..

My bedtime will be: ……………..

       

My bedtime will be: ……………..

My bedtime will be: ……………..

My bedtime will be: ……………..

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Bright Light Therapy – Morning

Research has found that feeling sleepy and the desire to sleep is associated with the production and release of a hormone called melatonin, which then leads to a decrease in body temperature. The release of melatonin (and change in body temperature) is usually synchronised with the pattern of sleep at night, and being awake and alert during the day. However if, for example, you do not fall asleep until 2am, and then nd it hard to wake up until 9am, the release of melatonin for sleep is occurring too late in the evening.

This problem with delayed sleep is especially common among young people, who tend to sleep in until late in the day when they don’t have to get up – like on weekends.

Our biological clock is in uenced by the cycle of light and darkness (night and day). Light (through our eyes) stimulates
a location in the brain that governs the release of melatonin. More exposure to light early in the morning (between 6am and 9am) results in melatonin levels quickly dropping and the body temperature rising. This in turn can begin to alter the time when melatonin is released (and the body temperature drops) in the evening: it will occur earlier, readying the body for sleep. In this way, Bright Light Therapy early in the morning can help you feel sleepy earlier in the evening. It can help synchronise the day and night cycle with the melatonin and body temperature cycle.

  

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Here is what to do:
Step 1
Keep to a regular wake-up time every day – including on

weekends.

Step 2 Expose your vision to bright light (sunlight) between 6am and 9am. 20 minutes of exposure on a bright sunny day may be enough, but if there is cloud cover, or if it is a dull day, 30 to 60 minutes will be needed.
never look directly at the sun; instead look into a sunlit environment or the sky. Do not wear sunglasses.
It may be easiest to accomplish bright light exposure through a daily routine of morning walking, gardening, or some other outdoor activity.

Step 3 Avoid bright light in the evening so that your body gets the clear message that it is not daytime.

Though Bright Light Therapy (morning) should improve your sleep pattern within a few days, you will probably need to keep it up for about a month to establish your new sleep-wake cycle. If you experience relapse, then simply recommence the therapy.

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Bright Light Therapy Evening

The tendency to fall asleep too early in the evening (before
9pm) and then waking very early and not being able to get
back to sleep, is a common problem for older people (who
are undergoing changes in their body temperature cycle), shift workers, and people experiencing a prolonged illness. Jet lag may be another factor associated with the problem of an advanced sleep pattern.

The principle of Bright Light Therapy in the evening is that it sends a message to the brain to delay the release of melatonin and a decrease in body temperature until later in the evening. This also has the effect of delaying the nal wake-up time, so that early morning awakenings become less frequent.

Here is what to do:

Step 1 Spend 30 to 60 minutes outdoors late in the day or early evening. If there is cloud cover you may need at least 60 minutes outdoors. In winter, you may need to speak to your doctor about obtaining a Light Box. Arti cial light exposure between 8pm and 10pm has been found to be effective. Other indoor bright lights (like a desk lamp) may also be of some value.

Step 2 Avoid morning sunlight and other bright light within one to two hours after waking.

Step 3 Get light exercise early in the evening (20 to 30 minutes). This raises body temperature, lowers melatonin, and can improve sleep four to six hours later. Avoid strenuous exercise early in the morning.

  

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An improvement in sleep pattern should occur within a few days. Therapy should continue for a month. If relapse occurs it can be recommenced.

For older people, general evening light exposure may need to become an ongoing part of their lifestyle.

Adapted from: Insomnia Management. (Adelaide, Department of Human Services: Environment Health Branch, 2000).

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Structured Problem-Solving

Worrying about problems before bed can make it very dif cult to get to sleep.That is why it is best to set aside time for problem- solving during the day.

Structured problem-solving is a method designed to help you feel in control of a problem, and to nd a way through it. Even if a problem can’t be fully solved during the day, at least having used a documented method you will have made a start, and have less cause to feel anxious and out of control at the end of the day or at bedtime.

The key elements of this method include:

• identifying and ‘pinning down’ the problem that has contributed to you feeling anxious or overwhelmed

• thinking clearly and constructively about the problem

• ‘taking stock’ of how you’ve coped in the past: your
personal strengths, and the support and resources available
to you

• providing a sound basis for important decision-making.

  

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Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly − including good and not so good options); write them down:

 

STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

 

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a. b.

c. d.

For more information, see Fact sheet 10 Changing your thinking at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?

What still needs to be done?

      

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Conflict

Con icts

Con ict happens when we discover we disagree with another person about something – which can be a useful discovery if we make an effort to handle it in the right way. It often carries with
it some strong feelings, which have the potential to either fuel a process of problem-solving, negotiation, and resolution – or more heated con ict into all out war!

Con ict that is quite minor may not need any kind of thoughtful process to resolve it. A little time may suf ce; although how you feel about it and how your partner, friend or colleague feels may vary.

Even with the best intentions, not all con ict can be resolved immediately. Accepting change in a relationship – new ideas, different ways of thinking and going about things – may need some time for adjustment.

IMPORTANT

• A healthy relationship is an evolving, changing relationship. It is exible and able to adapt to changing needs, beliefs, values, ideas, and circumstances.

• Con ict is an inevitable and unavoidable part of a healthy relationship.That’s why knowing how to work with con ict is so important.

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The Potential of Con ict

Positive Potential

Dealt with well, con ict can have some quite positive outcomes for a relationship:

• People can get to know each other better: what they think, how they feel, and what is important to them.

• Energy is released that can break through obstacles to make necessary change and improvement occur.

• It can clarify and ‘clear up’ false beliefs, misconceptions and false assumptions.

• It can disperse tension and stress, and bring relief and relaxation.

• It can help a relationship evolve, move forward, and
strengthen.
negative Potential
Con ict that is dealt with poorly can have quite negative consequences for a relationship:

• Con ict that is prolonged and not properly ‘worked with’ can be very damaging for both people and the relationship.

• Avoiding con ict can cause anger and resentment to build up and explode, causing damage hugely disproportional to the issue that caused the con ict in the rst place.

• Suppression of con ict prevents opportunities for individuals to make the changes and adjustments necessary in a relationship, and to stay ‘connected,’ when faced with the inevitable emergence of differences and different needs.

• To ignore con ict is to ignore and devalue the very differences that may have attracted 2 people to each other, and that give the relationship energy and variety.

• The more poorly con ict is handled, the more trivial will be the things that trigger it and the more habitual con ict will likely become.

• Con ict left unresolved can cause growing confusion, exaggeration, and feelings of powerlessness, helplessness, and despair – ingredients that can contribute to the development of anxiety or depression.

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Working with Con ict

Working with con ict means resolving con ict by using it to achieve a positive outcome, or at least an outcome that is better than continuing con ict.

There are a number of ‘tools’ and guidelines that are generally needed for this task:

You need to have the will

You have to be genuine about having the will to resolve con ict. Are you prepared to make concessions and do the work, or do you really just want to vent anger or resentment? You will need to say how you feel, but that is quite different to launching a personal attack, blaming, or accusing – all of which are counter- productive.

‘Set the stage’ for working with con ict

• If you have the energy and you are calm enough (if not, delay), identify, acknowledge, say what the con ict is in your view, and allow the other person to express his/her view (without interrupting or being ‘hooked’ into an argument).

• Decide that for your part you will remain calm and respectful (even if the other person doesn’t).

• Decide that you won’t make things worse by using put- downs, making nasty remarks, accusing, blaming, screaming, shouting or threatening, or by being loud or overbearing.

• Decide that you won’t try to get your own way by using tears, false information, aggression, anger, or manipulation (like using guilt or mind games).

• Ask the other person if he/she would be prepared to help work out a solution with you or a way of resolving your difference.

  

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• Say how you feel about the issue without elaborating, blaming, insinuating, or accusing. Your feelings are valid but, if you take them out on the other person, chances are he/ she will become angry and you will lose the opportunity to discuss the issue.

• Having both acknowledged the con ict, and having agreed to work it out, decide together when you will do so. Now may not be a good time, because of high emotion, too little energy, or the time, place or circumstances are inappropriate.
Explore and de ne the problem

• It is crucial to effective con ict resolution to clearly de ne the problem together. There are several things to consider here:

−  In de ning the problem (and issues), don’t ‘rope in’ other issues and feelings that don’t belong; these are probably best dealt with at another time.

−  Listen to each other patiently and without interruption. Make a real effort to understand the other person’s point of view:Try to imagine yourself in his/her position. Be courteous, give the person your full attention (rather than rehearsing what you are going to say, in your mind), and allow him/her at least equal time to speak.

−  Be really honest and open about what you might have done to make the con ict or disagreement worse. Don’t demand or expect the same concession from the other person.

−  Avoid any criticism of the other person’s view and don’t discount his/her feelings. Should it be the case that the other person is rigid in his/her view, criticism may merely serve to reinforce the person’s rigidity. Freedom from criticism and pressure leaves open the possibility of a ‘change of heart.’

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Find a Solution

This is the part of the process for resolving con ict that can require courage (to accept change), humility (being prepared to make concessions), empathy (appreciating their point of view and experience), and forgiveness (being prepared to ‘bury the hatchet,’ and truly relinquish any ill-feeling, to allow for a fresh start).

Do some brainstorming: think of a range of ways in which your disagreement or con ict could be resolved:

• What do you both need or want?

• How would things need to be different for you both to feel
comfortable?

• What would need to change?

• What compromise or concessions are you both prepared
to accept?

• Con ict resolution works only when you don’t need, or insist on gaining, the upper hand – which just makes the other person the loser. Some immediate compromise may be necessary. In time, one or both of you may feel differently and have a change of heart – away from the more de nite position currently held. Sometimes, being prepared to compromise a little can go a long way
to cooling down the con ict and any likelihood of it continuing.

• Con ict resolution is about working together to nd a solution that doesn’t leave either of you feeling cheated or the loser. If you win, the chances are, you have lost.The problem will merely have been obscured, and the other person’s feelings overridden. Both will likely return with a vengeance!

Remember to remain calm, patient, and respectful.

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• The real value of any solution is that it can pass the test of these questions:

−  Does this solution leave us both suf ciently satis ed not to want to harbour anger, resentment, annoyance or ill will, from now on?

−  Does this solution leave me feeling heard, respected, and valued?

−  Does this solution allow me to be true to myself and my needs?
Carry out the solution

• Write down what you have both agreed to work on, do, or change.

• Carry out the solution.

• If something happens that means you can’t keep up your part of the agreement, discuss this openly and honestly with the other person, and renegotiate an agreeable alternative.

• If a solution doesn’t look like it’s going to work, invite the other person to work with you on nding a new one.
Agree on a date for review

• Agree on a date to review how well the solution has worked or is working.

• If there is a problem, you can work together to solve it before con ict occurs again.

 

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What to do if things can’t be worked out

Sometimes, with the best will in the world, it just doesn’t seem possible to resolve a con ict ourselves – perhaps because feelings are too strong, or the issues are very dif cult or complicated. A third person from outside the situation can be very helpful in providing some objectivity, assisting us to think more broadly and creatively, and perhaps to make better sense of what we want, mean, feel, and can reasonably expect of each other.

Because con ict resolution requires time, energy, honesty, and vulnerability, it pays to try to nd the right person to help you ‘ rst time around’ rather than having to go over the matter again with someone else.

Speak to your doctor, or contact a health professional to have someone recommended to you. (Obviously, you will need to discuss this with, and gain the agreement of, the person with whom you are in con ict.) It is rarely the case that con ict can’t be resolved with some competent assistance.

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CONFLICT

Summary of Tools and Guidelines for Resolving Con ict

You need to have the will

Set the stage for working with con ict

Explore and de ne the problem

Find a solution

Carry out the solution

Agree on a date for review

What to do if things can’t be worked out

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CONFLICT

Anger

  

Signs of a Problem with Anger

Tickþthe signs that are familiar
r Feeling tense, on edge, and reactive much of the time

rAnger has become the rst response to almost anything that ‘goes wrong’ or goes ‘contrary to plan’

rSmall annoyances trigger an angry response
r Reacting to some things in a way that is ‘over the top’ or

excessive

r Blaming, accusing or criticising a partner or others is becoming frequent

rAnger about a particular issue builds up quickly and takes a long time to settle down

r Other emotions are not experienced much; they seem to merge into anger

r Feeling sometimes like smashing something, because of intense anger

r Shouting, screaming or yelling at a partner or children has become more frequent or intense, and is a concern

r Using anger to get people to cooperate, but there are bad feelings afterwards

r Being aggressive, threatening, and overly confrontational with other people

rFeeling like hurting oneself or someone else rExpressing anger in violent behaviour

If some of these signs are familiar –

.TAKE ACTIon.
Read thoroughly and apply the strategies in this section, including:

About Anger and Using and Managing Anger Effectively 160

ANGER

  

If you are fearful of expressing anger violently or this has already occurred, or if you have tried to manage your anger and have been unsuccessful –

.TAKE ACTIon.
Phone your nearest Community Health Service, or ask your

doctor to recommend a skilled counsellor or psychotherapist.

For a man seeking such assistance, it is reasonable to ask for someone with experience and knowledge appropriate to working with men.

If no one suitable is available locally, make the trip to where there is someone who can provide skilled assistance.

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ANGER

Anger, if not given thoughtful direction, will nd its own target.

 

About Anger

Despite anger having had a lot of bad press, it is, nevertheless, a normal, natural, and useful human emotion. We experience anger in situations where we:

• feel powerless or ‘forced into a corner’

• are mistreated or believe we have been mistreated

• are unable to feel in control in a situation we feel responsible for, or that needs to be brought under control

• have been made to feel embarrassed, or have been shamed or humiliated

• experience an event that taps into strong feelings unresolved from a situation that occurred in the past

• believe an injustice has been done to us or someone else we care about

• are fearful, but may not be fully aware of it.
The common denominator in all these situations is some sense of feeling powerless; and so the best use of the energy associated with anger is to direct it into what it is that is causing us to feel powerless.
Anger is a powerful emotion that needs to be used thoughtfully and not unfairly targeted at ourselves or someone else.

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ANGER

Anger can be very helpful in:

• motivating us to nd a solution to an injustice

• pushing us beyond our usual boundaries to examine how
reasonable or fair our expectations of another person are

• causing us to face issues that may have been ignored previously, that need thought, decision, and action

• driving towards goals and constructively solving problems

• facing and dealing with things that are feared

• prompting us to communicate with others about how we feel and what we think about certain issues

• energising and motivating us to stand up for ourselves

• enabling us to accept or pursue major changes in our
behaviour, priorities, or lifestyle.
Anger that lacks thoughtful direction, or that is simply ‘bottled up’ or covered over (such as with alcohol), has the potential to:

• grow in intensity

• become a more frequent and common response

• become more thoughtless and impulsive

• overshadow a person’s whole behaviour and personality

• become explosive, violent, and destructive.
Frequent or prolonged anger is associated with depression, anxiety, and insomnia, and a whole range of physical health conditions such as high blood pressure, suppressed immune system, ulcers, irritable bowel syndrome, heart disease, and stroke.

Frequent or chronic anger can lead to serious ill-health and relationship problems.

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ANGER

 

Anger that is not used appropriately (i.e. to solve problems
and address issues) can be highly corrosive and damaging to relationships. It tends to leave little scope for con ict resolution, for compromise or concessions. It polarises people, reinforcing difference and disagreement, and escalating tension and ill-feeling.

Anger often displaces or devalues those aspects of a relationship that are so important to it being meaningful, like: respect, thoughtfulness, sensitivity, understanding, and empathy. Suppressed anger, when it nally cannot be contained any longer, often targets those who are least deserving of it, and is hugely out of proportion to the issue blamed as its cause.

Anger and the ‘Fight or Flight’ response

Feeling angry occurs in conjunction with a general experience of heightened mental and physical arousal, referred to as the ‘ ght or ight’ response.This arousal is due to the body undergoing a series of biochemical changes in order to prepare us to deal with, or ee from, something that is perceived as a threat.

This was common in our more primitive past, when people frequently needed quick bursts of energy, as their bodies prepared to ght off or ee from ferocious predators or enemies. This remains an important response when we are faced with a real threat or danger. In other circumstances, it is less helpful, because it can also occur in response to threats that are imagined or thought to exist, and yet which do not.

Being too often in a state of ‘ ght or ight’ can have serious health implications (already alluded to in reference to frequent or chronic anger).

ANGER

164

Situation or event that is perceived as dangerous or threatening

The ‘Fight or Flight’ response

Brain activates fight or flight response

A series of biochemical changes occur in the body to prepare for conflict or escape

     

165

ANGER

Stop

 

Using and managing anger effectively

To make good use of anger, it is important not to let it build
up to the point where it is explosive, overwhelming, or out of control. It is vital to try to moderate anger if it is quickly building up, so that there is opportunity to consider what needs to be resolved and how (i.e. what generated the anger, and how the problem, threat or issue can be dealt with or resolved). There are some simple strategies that can be used for this:

the escalation of anger –

• Decide not to retaliate, blame, accuse, or insult.

• Withdraw physically from the situation, if possible, to take some time to calm down and consider what has happened, and what to do.

• If you are unable to withdraw immediately and you are being verbally assaulted,‘needled’ or provoked, activate
an imaginary mind shield.You can do this by electing a suitable ‘switch’ or ‘button,’ like touching or gently pressing the back of your neck with your nger, or pressing the tips of a nger and thumb together. When you do this, you can imagine a shield being activated that doesn’t block your hearing, but does protect your mind, so that what is being said doesn’t affect you.

• Remove yourself to a place where you can relax, and use a proven relaxation technique (see the Progressive Muscle Relaxation technique on page 174).
Relaxation, particularly of a kind that releases muscle tension, can help turn off the ‘ ght or ight’ response. The nerves in muscles that are relaxed change the type of signals they transmit to the brain. The brain then stops

166

ANGER

sending panic messages to the body’s nervous system, and a general feeling of physical and mental calmness begins to prevail.

• For people who are often angry, there is little opportunity for high levels of muscle tension to diminish. The consequence of living with a high level of tension is that a state of tension becomes ‘normal’ and is taken for granted; so that being tense isn’t noticed. Becoming aware of tension in our body, and taking steps to release it, is crucial to the management of anger – and to maintaining good mental and physical health.

Recognising Tension

Ask yourself these questions:

• Where do I feel tension?
– In which parts of my body? – In which muscles?

• What does the tension feel like? – Is there hardness?
– Is there fatigue?
– Is there an ache or pain?

• What is it that has led to this tension?

• Is this tension helpful or unhelpful?

• Do I need to make time to relax?

167

ANGER

ConSIDER

what caused the anger and how the problem, threat or issue can be dealt with or resolved.

Why am I (or was I) angry?

The best use of anger is to direct it into the problem, threat or issue that is its source, thus avoiding directing it at ourselves or someone else. To trace anger back to its cause or source can usually be done by simply exploring:

• What happened – what was said or done that I perceived as a threat, a put-down, an embarrassment, or an injustice?

• What happened, has been happening, or is happening, that: − leaves me feeling powerless?
− forces me into a corner?
− puts me under unfair pressure?

• What has been done to me, has affected me, hurt, or threatened me, over which I have had little or no control?

• Is what has happened or is happening stopped me from doing what I think it is my role or responsibility to do?

• Do I feel angry because this is like something that has happened before or in the past, about which I still feel angry?

• Am I angry about a minor issue, which has unleashed stored up anger from other issues that I haven’t properly faced or dealt with?

• Do I feel angry because another person has not done something I think he/she should have, or that I would have preferred? Are my expectations reasonable? Do I need to think about things from the other person’s point of view?

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ANGER

What can I do about the problem?

How can the problem, threat or issue, that is the source of my anger, be resolved? Often anger can be resolved, and the ‘ ght or ight’ arousal state turned off, simply by thinking constructively (rather than defensively), and working out how to deal with an issue. Taking the initiative can give us back a sense of being more in control, and is an effective antidote to feeling powerless.

On consideration of the source of our anger, it may turn out that we have ‘jumped to conclusions,’ not considered another person’s point of view, or have had unfair or unreasonable expectations of them.

On the other hand, it may be that we have unreasonable expectations of ourselves, like always thinking: “I should,” “I must,” “I have to.” If we are too rigid in what we expect of ourselves, sooner or later we will nd ourselves unable to do what we think we must, and will feel threatened, powerless, and angry.

other things to consider include:

• How could I try to explain or express to another person how I experienced something they have done?

• What kind of compromise could be made that respects both of our points of view?

• Do I need to consider a more formal process of con ict resolution? (See the chapter on Con ict, page 149.)

• Am I angry about something that happened in the past that is really confusing or complicated, which I can’t resolve without some professional support?

• Is the unfairness, injustice or cruelty that generates my anger, something I need to get support and expert advice in order to tackle?

• Do I need to use structured problem-solving with some of the issues?

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ANGER

ACT

SToP ConSIDER

• Am I calm enough and prepared enough to talk to the other person/people, and/or to tackle the issue with them?

to try to resolve or address the issue/problem you have considered.

• Be determined but calm.

• Be clear about what you want – or don’t want.

• Be exible but not sidetracked.

• Stick to the issues (don’t ‘rope in’ other issues).

• Be prepared to apologise if that is fair and appropriate.

• Seek the support, help or expertise of others, if that is
needed and appropriate.
If you can’t seem to get the issues resolved because of more anger, or because another person (or persons) can’t agree or are not interested in your approach, go back immediately to:
and then

170

ANGER

SToP

and/or

ConSIDER

REMEMBER

  Decide not to retaliate, blame, accuse, or insult

  Withdraw physically from the situation

  Activate a ‘mind shield’

  Go somewhere to relax; become aware of and
release tension

  Why am I (or was I) angry? Where does it stem from?

−  Feeling powerless?

−  Unfair pressure?

−  Something happening/happened over
which I have no control?

−  Unmet expectations?

−  Taps into an old issue or built up anger?

  What can I do about the problem?

−  Need to think constructively rather than
defensively?

−  Do I have reasonable expectations?

−  Have I jumped to conclusions?

−  How could I try to explain how I feel?

−  Compromise?

−  Is a process of conflict resolution needed?

−  Is this unresolvable without professional
support?

−  Do I need to problem solve the issue?

−  Is this something that requires support and
expert advice?

−  Am I calm enough and prepared enough to
act?

  Try now to resolve or address the issue/problem you have considered.

−  Be determined, calm, and clear about what you want – or don’t want

−  Stick to the issue; don’t be sidetracked, but be flexible

−  Be prepared to apologise if that is fair and appropriate

−  Get the support, help, or expertise of others if needed

ACT

171

ANGER

SToP ConSIDER

Have you succeeded to a degree that the problem/issue no longer generates anger, or only generates energy and resolve useful to addressing the issue, or getting the problem solved?

YES r
NO r go back to

and

Further hints on managing anger

1. List the things that trigger your anger (from worst to least). Work on these things; seek to resolve them or rehearse how to respond to them better, before they occur again.

2. Practise the skills suggested (for using and managing anger effectively) with problems or issues that are easily manageable, in readiness for more dif cult challenges later on.

3. Make getting plenty of sleep a priority. Sleeping poorly makes us much more susceptible to irritability and anger, and leaves us with little energy for tackling issues or problems constructively. If sleep is a problem, see the chapter on Insomnia (page 119).

4. Get regular daily exercise, dedicated to improving your mental and physical health (i.e. separate from work).

5. If you feel under a lot of stress, that may be contributing to your sense of powerlessness and your experience of anger. Consider some of the strategies for managing stress in the chapter on Stress (page 177).

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ANGER

What if nothing seems to work?

Sometimes it just doesn’t seem possible to do anything about an issue or a problem that leaves us feeling angry. Yet, even though there may appear to be no way in which we can utilise anger to resolve an issue or problem, anger can still be managed and kept from being targeted at ourselves or others by:

• using a relaxation technique frequently

• exercising regularly

• resisting the urge to keep dwelling on the issue (with our thoughts and what we say to ourselves in our head)

• travelling to where we can speak to a skilled counsellor or psychotherapist (ask your doctor for a referral or recommendation)

• using a ritual, like writing about the source and experience of our anger, putting what we’ve written down in an envelope or container, and then placing it somewhere away from us – symbolically distancing ourselves from it, until we decide to revisit or abandon it.
If anger is caused by bullying, harassment or discrimination at work, or in dealing with a person or organisation, get some advice about your rights and how best to deal with the issues.
If you have tried to manage your anger and have failed, or if you are fearful of becoming (or have been) violent –
.TAKE ACTIon.
Phone your nearest Community Health Service, or ask your
doctor to recommend a skilled counsellor or psychotherapist.
For a man seeking such assistance, it is reasonable to ask for someone with experience and knowledge appropriate to working with men.

173

ANGER

 

If no one suitable is available locally, make the trip to where there is someone who can provide skilled professional assistance.

Progressive Muscle Relaxation

A method of relaxation with proven effectiveness which relieves muscle tension, and can help switch off the ‘ ght or ight’ anxiety response, is Progressive Muscle Relaxation. This involves tensing and then relaxing muscles in a step-by-step sequence. The two main principles of this technique include:

1. Tensing muscle groups (one at a time) to become aware of the feeling of tension.

2. Relaxing the muscles and feeling the tension in them subside – as if owing out of the body.

ANGER

174

Progressive Muscle Relaxation

• You will need about 15 minutes for this relaxation exercise.

• Find a quiet place where you won’t be interrupted.

• Sit in a comfortable straight-backed chair, with your feet
at on the oor.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Tense each of the following muscle groups for 5 seconds, then relax them completely for 15-20 seconds (pay particular attention to the different sensations of tension and relaxation):

1. Curl both your sts and tighten your biceps and forearms (as if lifting weights). Relax.

2. Wrinkle up your forehead; tighten the muscles in your face causing your face to wrinkle; purse your lips and press your tongue against the roof of your mouth; hunch your shoulders. Relax.

3. Arch your back as you take a deep breath into your chest. Relax.

4. Taking a deep breath, gently push out your stomach. Relax.

5. Pull your feet and toes backwards tightening your shins. Relax.

6. Curl your toes at the same time as tightening your calves, thighs and buttocks. Relax.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Now resume normal activities in a calm and peaceful manner.

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ANGER

 

Tips and cautions on the use of Progressive Muscle Relaxation

• Be patient with yourself and this technique. You may experience only partial success at rst. In time, it should be possible for you to relax your whole body quickly and successfully. Practise is the key.

• Be careful when you are tensing your neck and back. Excessive tightening could result in muscle or spinal damage. Over-tightening your toes or feet could result in muscle cramping.

• To achieve the best results with this technique, it is important to let go of the tension in a group of muscles you have tensed instantly. Releasing tension slowly may seem to relax muscles, when in fact it may just sustain tension. When you release muscle tension, do it instantly and let the muscles suddenly become limp.

ANGER

Adapted from: Davis, M. et al. The Relaxation and Stress Reduction Workbook Fourth edition (U.S.A., New Harbinger Publications, 1995) Chapter 4.

176

Stress

Warning Signs of Stress

Tickþthe signs that are familiar

r Problems getting to sleep and/or staying asleep r Constant fatigue
r Poor concentration or forgetfulness
r Feeling fearful, anxious or overwhelmed

r Frequent urination
r Nervous diarrhoea
r Over-reaction to small things
r Frequent anger or frustration
r Light-headedness
r Lowered sexual desire and/or performance
r Muscle tension or pain
r Faintness, dizziness
r Poor appetite
r Being jumpy or easily startled
r Sweating, shaking, or nervousness
r Stomach cramps
r Shortness of breath without exercising
r Reduced work ef ciency
r Over-use of alcohol or misuse of prescribed drugs r Headaches or migraines
r Heartburn
r Moodiness
r Skin rashes

If you have some of these symptoms and they are affecting your life –

.TAKE ACTIon. Arrange to speak to a doctor

  

STRESS

 

178

About Stress

We all know what it is to experience stress, and we usually have a pretty good idea of the kinds of things that seem to generate it (which are termed stressors). Trying to create a stress-free
life would be both unrealistic and undesirable, since stress is associated with work, family, and personal relationships – in

fact, with nearly all the changes and challenges that enable us to develop, adapt, and make our way successfully through life.

Some stress is actually quite bene cial to us, because it can generate energy, alertness, and motivation for a whole range of tasks. The problem arises when we experience too much stress at one time, or experience signi cant stress for a prolonged period of time. Severe or prolonged stress can have quite negative effects: it is associated with increased risk for many health problems – including some mental health problems:

• re ux, hyperacidity, heartburn, esophageal in ammation

• irritable bowel syndrome

• ulcers

• diarrhoea, constipation

• indigestion

• high blood pressure

• heart disease

• stroke

• bladder infection

• high cholesterol

• immune system related disorders

• asthma

• allergies and skin diseases

• colds and infections

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STRESS

• muscle spasm, muscle pains

• motility disturbance

• cancer

• neuro degenerative disorders

• fatigue

• anxiety

• depression

• insomnia

• alcohol and drug misuse and dependence

• concentration and memory problems.
Stress is far from being ‘all in the mind,’ since stressful events can trigger a whole series of biochemical changes in the body that are experienced physically as well as psychologically. And though the effects of stress differ from person to person, none of us is immune; no matter how ‘easy going’ we are, one day, it could affect us profoundly, especially if we’re confronted by an unfamiliar and particularly dif cult situation, which we don’t have the coping resources to deal with.
Stress is an everyday fact of life. Its effects can be anything from minor and helpful, to severe and damaging. It can occur as a result of major life changes and challenges, or just the cumulative effect of many everyday worries.
The good news is: stress can be managed; it can be reduced and it can be kept at a level that is useful rather than harmful.

 

STRESS

180

Stress management involves:

 

Awareness and understanding Using stress reduction strategies Making healthy choices

 

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Sources of Stress

There are a variety of sources from which we can experience stress, they include:

Our physical environment

We live in a dynamic, ever-changing and demanding physical environment. We are constantly responding and making adjustments to sounds, the weather (changes in temperature, humidity, and seasons; the possibility of ooding, drought, re, and high winds), dangers, and challenges, in the course of moving about and travelling.

Our social environment

We have to cope with many social stressors, such as listening to and interacting with other people, work commitments, managing nances, dealing with disagreement and con ict, responding to many competing demands for our time, decision making and responding to problems, being interviewed or giving a speech, grieving losses of many kinds (perhaps including bereavement, separation/divorce, or loss of a job or livelihood), marriage, child rearing, and community commitments.

   

STRESS

182

Life transitions and physical changes

We make transitions from childhood to adulthood to old age; from being single to being partnered; childless to having children; work to retirement.We experience many physical changes and challenges due to puberty, pregnancy, illness, menopause, old
age, accident, sickness, inappropriate nutrition, lack of exercise, and sleep disturbance.There are also many body changes and symptoms that occur as a result of our reactions to threats and changes in our physical and social environments, such as: muscle tension, headaches and stomach upset, raised blood pressure, anxiety, and memory disturbance.

Our thoughts and self-talk

How our brain interprets and makes sense of life events, challenges, tasks, and experiences, if mostly or often negative, can be a signi cant source of stress for us. Because how we think and what we say to ourselves in our head (self-talk) are largely within our control, managing these thoughts is a very useful stress-reduction strategy (on which we will focus in this section). Though there are many sources of stress over which we have little control, we do have some choice about our thoughts and self-talk.

 

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STRESS

The ‘Fight or Flight’ response

Although there are many sources of stress over which we have little control (as already mentioned), how we interpret and
make sense of life events, challenges, tasks, and experiences −
and what we predict about the future from them − can serve either to simply engage us in a relatively calm response (even though perhaps feeling some emotion), or cause us to experience anxious arousal, more commonly referred to as being ‘stressed.’

For example, if your friend is short with you and you don’t hear from the person for a couple of days, it could be interpreted as meaning that something you have done (or not done) has caused the person to behave this way. This predicts for the future:

ill feeling, avoidance, and all the pain of either trying to work things out or living with a broken friendship. This would be very anxiety-provoking or stressful; you would experience anxious arousal. But what if, alternatively, you simply viewed the person’s behaviour as being due to tiredness or something bad happening at home? You would experience the person’s behaviour quite differently. It would be unlikely to trigger much anxious arousal at all.

The experience of anxious arousal or stress is actually the effect of what has been termed the ‘ ght or ight’ response.

When we are threatened by something or are in danger, our body responds with a series of biochemical changes aimed at preparing us to ght or escape. This was common in our more primitive past, when people frequently needed quick bursts

of energy, as their bodies prepared to ght off or ee from ferocious predators or enemies. This remains an important response when we are faced with a real threat or danger. The problem is, our brain (in activating the ‘ ght or ight’ response) does not distinguish between what is real and what is imagined.

184

  

STRESS

Many novice public speakers would confess that giving a speech
– even to a sympathetic audience – can generate as much terror and anxiety as any real physical danger or threat. What we imagine or perceive as threatening, and the way we anticipate problems or challenges in the future, whether real or not, may be ‘real’ enough for our brain to activate a response, and for us to feel stressed.

Severe stress is the result of the ‘ ght or ight’ response occurring repeatedly for a prolonged period.

Situation or event that is perceived as dangerous or threatening

Brain activates fight or flight response

A series of biochemical changes occur in the body to prepare for conflict or escape

     

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STRESS

Changes that occur due to the ‘Fight or Flight’ response

• The mind becomes alert.

• Blood clotting ability increases, preparing for possible
injury.

• Heart rate speeds up and blood pressure rises.

• Sweating increases to help cool the body.

• Blood is diverted to the muscles which tense ready for action.

• Digestion slows down.

• Saliva production decreases causing a dry mouth.

• Breathing rate speeds up – nostrils and air passages in lungs open wider to take in air more quickly.

• Liver releases sugar to provide energy quickly.

• Sphincter muscles contract to close the openings of the
bowel and bladder.

• Immune responses decrease (which is useful in the short- term to allow massive response to immediate threat, but can become harmful over a long period).

• Fear and apprehension

• Trembling or shaking

• Restlessness

• Cold and clammy hands

• Hot ushes or chills

• Feeling sick or nauseous

• Butter ies in the stomach
Excerpt from: Management of Mental Health Disorders Third edition (World Health Organization, 2000) Vol 1, page 295.

STRESS

186

Stress Reduction Strategies

There is a range of strategies that have proven to be helpful in the reduction and management of stress.

Those that are most effective in switching off the ‘ ght or ight’ response are:

• Relaxation

• Adopting constructive thought patterns (revising
how we interpret and make sense of life events) Other important strategies include:

• structured problem-solving

• restoring a pattern of normal sleep

• reducing alcohol and caffeine consumption

• making healthy choices.

For more information, see Fact sheet 6 Reducing stress at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

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Recognising Tension

Ask yourself these questions:

• Where do I feel tension?
– In which parts of my body? – In which muscles?

• What does the tension feel like? – Is there hardness?
– Is there fatigue?
– Is there an ache or pain?

• What is it that has led to this tension?

• Is this tension helpful or unhelpful?

• Do I need to make time to relax?

Relaxation

When we use a method of relaxation that can enable us to release tension in our muscles, the nerves in our muscles change the type of signals they transmit to the brain. The brain then stops sending panic messages to our nervous system, and a general feeling of physical and mental calmness begins to prevail.

For people who are often stressed, there is little opportunity for high levels of muscle tension to diminish. The consequence of living with a high level of tension is that a state of tension becomes ‘normal’ and is taken for granted; so that being tense isn’t noticed.

Becoming aware of tension in our body, and taking steps to release it through effective relaxation, is a vital strategy for stress reduction.

 

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Progressive Muscle Relaxation

Progressive Muscle Relaxation is a method of relaxation with proven effectiveness. It relieves muscle tension, and can help switch off the ‘ ght or ight’ anxiety response. This involves tensing and then relaxing muscles in a step-by-step sequence. The two main principles of this technique include:

1. Tensing muscle groups (one at a time) to become aware of the feeling of tension.

2. Relaxing the muscles and feeling the tension in them subside – as if owing out of the body.

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STRESS

Progressive Muscle Relaxation

• You will need about 15 minutes for this relaxation exercise.

• Find a quiet place where you won’t be interrupted.

• Sit in a comfortable straight-backed chair, with your feet at on the oor.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Tense each of the following muscle groups for 5 seconds, then relax them completely for 15-20 seconds (pay particular attention to the different sensations of tension and relaxation):

1. Curl both your sts and tighten your biceps and forearms (as if lifting weights). Relax.

2. Wrinkle up your forehead; tighten the muscles in your face causing your face to wrinkle; purse your lips and press your tongue against the roof of your mouth; hunch your shoulders. Relax.

3. Arch your back as you take a deep breath into your chest. Relax.

4. Taking a deep breath, gently push out your stomach. Relax.

5. Pull your feet and toes backwards tightening your shins. Relax.

6. Curl your toes at the same time as tightening your calves, thighs and buttocks. Relax.

• Close your eyes and use the controlled breathing technique for about 5 minutes.

• Now resume normal activities in a calm and peaceful manner.

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Tips and cautions on the use of progressive muscle relaxation

• Be patient with yourself and this technique.You may experience only partial success at rst. In time, it should be possible for you to relax your whole body quickly and successfully. Practise is the key.

• Be careful when you are tensing your neck and back. Excessive tightening could result in muscle or spinal damage. Over-tightening your toes or feet could result in muscle cramping.

• To achieve the best results with this technique, it is important to let go of the tension in a group of muscles you have tensed instantly. Releasing tension slowly may seem to relax muscles, when in fact it may just sustain tension.When you release muscle tension, do it instantly and let the muscles become limp suddenly.

Adapted from: Davis, M. et al. The Relaxation and Stress Reduction Workbook Fourth edition (U.S.A., New Harbinger Publications, 1995).

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Adopting a constructive mental pattern

What we perceive as dangerous or threatening activates the ‘ ght or ight’ response.When this perception changes – either because the danger or threat ceases, or because we alter the way we think about or interpret it (“This is not a threat or danger to me”), the ‘ ght or ight’ response is de-activated – turned off.

How we interpret life events (the things that happen to us, challenge us, make demands of us, or that we perceive may have consequences for us), has a huge bearing on how much stress or anxiety we experience.

Part of this interpreting is what we think, how we think, and what we say to ourselves in our head (our self-talk).

The kind of mental pattern or way of interpreting events that we use is generally either self-defeating or, alternatively, constructive.

Self-defeating interpretations (thoughts and self-talk) can generate high and unhealthy levels of stress or anxiety – as well as causing paralysis in attempts at problem-solving and decision- making.

Constructive interpretations (thoughts and self-talk) help to maintain healthy and useful levels of stress or anxiety, which permit and promote coping.

  

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192

Self-Defeating Interpretation

Self-defeating thoughts and self-talk

“I can’t even get on with my wife any more” “Even my marriage is a failure”

“I’m useless at this like everything else”

Event

Argument with wife

Experience

High level of stress/anxiety, causing difficulty in coping

  

Constructive Interpretation

Constructive thoughts and self-talk

“I don’t feel good about this, but we are both tense and on edge”
“Our relationship is OK. We will need to work this through when we are both calm”

Experience

Moderate level
of stress/anxiety, permitting and promoting coping

Event

Argument with wife

 

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Self-defeating interpretations also tend to become more entrenched, and stress or anxiety levels more unhealthy and unhelpful, as a self-reinforcing vicious cycle develops.

People who tend to use a self-defeating thought pattern in interpreting events also develop (mostly unconsciously) errors
in thinking which, like jumping to conclusions, may seem to save time and energy, but can actually have consequences that demand much time and energy.

Adopting a constructive thought pattern in interpreting events is essential for managing stress or anxiety, and for achieving and maintaining good mental health.

How can this be done?

It can be achieved through:

• becoming aware of how we respond to events (and what we think and say to ourselves in our heads)

• censoring and modifying our thoughts (especially those that are automatic) and self-talk

• challenging and dismantling errors in thinking.

   

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Becoming aware

We can simply decide to become aware of our thoughts and self-talk.This awareness provides us with the opportunity to change our thoughts and self-talk; it gives us the power of censorship.With practise, it is possible to exert in uence over our automatic thoughts (challenging and dismantling errors in thinking will help this too).

To get this awareness underway, it is helpful to do some initial documenting of situations/events to be examined, the feelings experienced, and the thoughts that occur. This is also a good way of identifying errors in thinking.

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

You discover one of your vehicle tyres is flat, and you were organised to go somewhere.

Immediate ‘welling up’ of stress and anxiety, then strong feelings of anger.

“No!” “Everything just has to go wrong;” “Like everything else around this place;” “I just don’t need this.”

Situation/Event

Feelings experienced

Automatic thoughts (and self-talk)

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Practising taking ‘snapshots’ of situations, and writing things down like this, is a useful tool for establishing awareness. After a while, this can be expanded into the skill of censoring and modifying thoughts and self-talk.

Censoring and modifying

The key to censoring and modifying (or managing) thoughts and self-talk is the speed with which we intervene and ask ourselves: is this thought/idea (or what I’ve begun saying to myself) self- defeating or constructive? If it is self-defeating, how can I modify it immediately or replace it, so that I am using a constructive mental pattern?

This is a skill to be practised and a new habit to be formed. As with becoming aware, it can be really helpful (at least initially), to write things down; when we can ‘see’ our thoughts and what we are saying to ourselves, we have more power to change them.

 

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Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

A friend, who you had arranged to come over and help you with something important, has left a message to cancel at the last minute.

“Great;” “Thanks a lot;” “Why is it I always get let down?”

Self-defeating, because I can feel stress and anger building up.

How do I know why
he cancelled….it could
have been an emergency. Everyone feels let down sometimes, that’s life. I’ve cancelled things too. There are other things I can do; this can be put on hold. It is alright.

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Situation/Event

My thoughts and self-talk

Are these self-defeating or constructive?

If self-defeating, what would be constructive?

Examples of common errors in thinking

Challenging and dismantling errors in thinking

Errors in thinking consist of certain assumptions and ways of thinking that keep recurring, are habitual, and allow us to save time by not thinking constructively about events. They provide an easy response, but one that is neither time-saving nor helpful. Errors in thinking ‘save a penny and spend a pound,’ because their consequences heavily tax our energy reserves, and generate high and unhealthy levels of stress or anxiety.

Errors in thinking need to be challenged and revised if we are to establish a constructive and healthy mental thought pattern.

 

Assumptions

All things are equally important and urgent

Challenge

Many things are not crucial or urgent. But they generate anxiety because I interpret them that way. Some things are crucial and/or urgent and cannot be left. Many things are not, and they can be postponed.

If I’m stressed or anxious, what does a thing matter, unless it is truly crucial or urgent?

This is not inevitable or necessary, it is a habit. Lots of other people take these things pretty much in their stride. No, getting uptight often,
is mostly because often I interpret events in a self- defeating way.

  

Getting uptight about unforeseen or unwanted events is inevitable

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Everything has to go wrong, life is against me succeeding

Based on what evidence? What about people who, against all apparent odds, still succeed? Do I need to examine how

I go about things? How I make decisions, and for what reasons?
If I expect things to go wrong, isn’t it highly likely I will contribute to that happening? Has ‘life’ really singled me out to be a victim?

What real evidence supports this assumption?
Are other people let down also? How does my experience compare with theirs?

Have I on occasions let others down?
Do I know anyone who always experiences other people as completely reliable?

Do I automatically believe the best or the worst when people appear to let me down? Are my expectations reasonable?

  

People always let me down

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If I could go back in time: … If I had…….
If only I did……

The benefit of hindsight is a fine thing. Of course I could be more knowledgeable, skilled, and wise if I could have been then who I am now,or if I could go back as who I am now.
How is this kind of thinking helpful?
I was who I was. I made decisions and did things as the person I was, and was capable of being then. No amount
of lamenting will change that. The only valid questions are perhaps:What can I learn
from the past? What can I
do differently now and in the future?

No one could live up to that, without lying about the many occasions when they, quite rightly, didn’t bother to do some things either perfectly or properly. Taking pride in doing important things well is admirable. But trying to

do everything perfectly or properly is not necessary, important, reasonable, or admirable. It is plain unhealthy! Perhaps what is more needful is to be able to prioritise?

    

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Everything has to be done perfectly or properly

200

other thinking habits:

— Mind-reading: — Catastrophising:

— Labelling:

— over-generalising: — Fortune-telling:

— ‘Rule-saying’:

— Black and white — thinking:

“She thinks I’m a failure;”
“They think I’m not as good as….”

“Everything always turns out bad for me;”
“Things are always against me;”
“Now I will never be able to….;” “No matter how hard I try everything always goes wrong.”

“I’m an idiot;” “I’m a failure;” “I’m a lousy…..” (Instead of “I did….poorly;” or “I did not achieve…..;” or “I needed to….”)

Saying,“Always,” “Never,” “No-one,” or “Everyone.”

“Everyone is sure to…..;”
“I’m sure to mess it up;”
“It’s going to be a disaster;”
“I’m sure to feel dreadful when I…..”

“Should,” “Must,” or “Have to” (setting sometimes unrealistic expectations).

“Everything she does she gets right;” “I’ve completely ruined everything;” “He succeeds in everything…… I never get it right!”

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Examples you can think of:

− − − −

 

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202

Structured Problem-Solving

For people who are stressed, it is common to feel threatened and overwhelmed by problems, and the thought of having to deal with them. So it can be really helpful to have a step-by-step methodical way of dealing with problems and making decisions. Through the method of structured problem-solving, it is possible to feel more in control of problems and to reduce signi cantly the feeling of being threatened or overwhelmed by them.

The key elements of this method include:

• identifying and ‘pinning down’ the problems that have
contributed to you feeling overwhelmed

• thinking clearly and constructively about problems

• ‘taking stock’ of how you’ve coped in the past: your personal strengths, and the support and resources available to you

• providing a sound basis for important decision-making. With this method, you can work on a single problem or follow
the process to tackle a number of problems.
Usually though – especially to begin with, it is best to deal with one problem that is speci c and potentially solvable.

For more informationsee Fact sheet 10 Changing your thinking at http://www.beyondblue.org.au or call the beyondblue info line
1300 22 4636

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1.

2.

3.

4.

5.

Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly − including good and not so good options); write them down:

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STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

1.

2.

3.

4.

5.

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1. a.

b.

c.

d.

2. a.

b.

c.

d.

3. a.

b.

c.

d.

4. a.

b.

c.

d.

5. a.

b.

c.

d.

STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________ ____________________________________________________

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Restoring a Pattern of Normal Sleep

Sleep disturbance is common for people who are stressed. To restore a pattern of normal sleep, it is important to practise sleep-promoting behaviour during the day, in the evening, at bedtime, and during the night.

Better Sleep Guidelines

During the day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns. Avoid exercise late in the evening, as this may make getting to sleep more dif cult.

• Set aside time for problem-solving and decision-making during the day to avoid worry or anxiety at night. (See Structured Problem-Solving on page 203.)

• Avoid napping during the day – go to bed and get up at regular times.
During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your diary to be dealt with tomorrow.

• Light exercise early in the evening may help sleep; exercise late in the evening may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

 

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• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa, and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep, and keep your intake moderate (limit yourself to 2 standard drinks each day).

• Make sure your bed and bedroom are comfortable – not too cold or warm.

• Ensure that your bedroom is dark and that the morning light does not lter in. However, if you have a tendency to oversleep, it may be helpful to let the morning light into the room.

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack might help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxing music, or using a relaxation technique (see Progressive Muscle Relaxation on page 189). This way, your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t read, watch TV or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual activity).

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready. Enjoy relaxing your mind and body, even if you don’t fall asleep at rst.

 

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During the night

• If you wake up too early in the night, don’t lie awake
for more than 30 minutes. Instead of just being awake
or worrying, get out of bed and do something that is distracting, yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, have earplugs handy to block out the noise.

• Avoid sleeping pills − they do not provide a long-term solution to sleep problems.

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Reducing Alcohol and Caffeine Consumption

The problem with alcohol and stress

It is common for people who are stressed to ‘settle the nerves’ or to cover their stress using alcohol.

There are several problems with this:

• Alcohol becomes a substitute for tackling the important issue of stress management.

• Dependence can quickly (but often unknowingly) occur, with alcohol being used more frequently for stress management.

• Usual coping strategies (even if only partially effective) become neglected and even less effective, when alcohol is used as a substitute.

• Alcohol can negatively affect the quality of sleep. As the alcohol is broken down in your body, it causes you to sleep less deeply and to wake more frequently.

• Alcohol can negatively affect the quality of your relationships.
Strategies for moderating alcohol consumption

• Try to avoid drinking at home alone – especially when you are feeling down or anxious.

• Try limiting your drinking to the evening meal time.

• Drink low alcohol beers and mixes.

• Drink slowly (limit yourself to 2 standard drinks each day).

• Think ahead (and creatively) about how to avoid drinking excessively in situations (like at the pub or social gatherings) where there is pressure to do so.

   

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• Alternate non-alcoholic with alcoholic beverages.

• Plan to have 2 alcohol-free days each week. Try to choose days when it will be easier to go without a drink. For example, if you have an activity planned for the evening, that may be a useful distraction.

• Decide beforehand how much alcohol you will permit yourself to drink; measure it out, and allow yourself only that amount.

• Always try to stay within the Australian Alcohol Guidelines.
For Men and Women
over a lifetime:
If you drink no more than 2 standard drinks a day, you reduce the lifetime risk of harming yourself from alcohol-related disease or injury.
on a single occasion: Having no more than 4 standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.
NUMBER OF STANDARD DRINKS – WINE
1.6 1 0.9 1.4 1
150ml 100ml 60ml 150ml 100ml

NUMBER OF STANDARD DRINKS – BEER

        

1.1

285ml
Full Strength 4.8% Alc. Vol

0.8

285ml Mid Strength 3.5% Alc. Vol

0.6

285ml Low Strength 2.7% Alc. Vol

1.6

425ml
Full Strength 4.8% Alc. Vol

1.2

425ml Mid Strength 3.5% Alc. Vol

34

24 x 375ml

Full Strength 4.8% Alc. Vol

0.9

425ml Low Strength 2.7% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

1.4

375ml
Full Strength 4.8% Alc. Vol

24

1

375ml Mid Strength 3.5% Alc. Vol

0.8

375ml Low Strength 2.7% Alc. Vol

     

1.4 1 0.8

19

24 x 375ml Low Strength 2.7% Alc. Vol

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

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1.4 1 0.8

34

24 x 375ml

Full Strength 4.8% Alc. Vol 34

24 x 375ml Full Strength

24

24 x 375ml Mid Strength 3.5% Alc. Vol

24 x 375ml Mid Strength

19

24 x 375ml Low Strength 2.7% Alc. Vol

24 x 375ml Low Strength

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

1.4 1 0.8

24

19

375ml 375ml 375ml Full Strength Mid Strength Low Strength

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres 2 Litres 750ml 4 Litres 2 Litres

2 Litres Cask of Port 17.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

Cask Red Wine Cask Red Wine Bottle of White Wine Cask White Wine Cask White Wine

13.5% Alc. Vol 13.5% Alc. Vol 12.5% Alc. Vol 12.5% Alc. Vol 12.5% Alc. Vol

* Ready-to-Drink

For more information see chapter on ALCoHoL (page 225)

212

4.8% Alc. Vol 3.5% Alc. Vol 2.7% Alc. Vol 4.8% Alc. Vol 3.5% Alc. Vol 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE

    

NUMBER OF STANDARD DRINKS – WINE

 

1.6 1 0.9 1.4 1

150ml Average Restaurant Serving of Re1d.6Wine 13.5%15A0lmc.l Vol

Average Restaurant Serving of Red Wine 13.5% Alc. Vol

100ml Standard Serve of Red Wine 13.5% A1lc. Vol

100ml Standard Serve of Red Wine 13.5% Alc. Vol

60ml Standard Serve of Port 18%0A.lc9. Vol

60ml Standard Serve of Port 18% Alc. Vol

150ml Average Restaurant Serving of Wh1it.e4Wine 11.5%15A0lmc.l Vol

Average Restaurant Serving of White Wine 11.5% Alc. Vol

100ml Standard Serve of White Wine 11.5% A1lc. Vol

100ml Standard Serve of White Wine 11.5% Alc. Vol

1.4

150ml

Average Restaurant

7.5

750ml
Bottle of Champagne 12.5% Alc. Vol

750ml
Bottle of Champagne 12.5% Alc. Vol

Serve of Champagne

1.4

 

12% Alc. Vol

7.5

150ml Average Restaurant Serve of Champagne 12% Alc. Vol

    

8 43 21 7.5 39 19.5 28

750ml
Bottle of Red Wine 13.5% Alc. Vol

4 Litres Cask Red Wine 13.5% Alc. Vol

2 Litres Cask Red Wine 13.5% Alc. Vol

750ml
Bottle of White Wine 12.5% Alc. Vol

4 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask White Wine 12.5% Alc. Vol

2 Litres Cask of Port 17.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

      

1.1

275ml
1 22 Full Strength

30ml 700ml RTD*
HighStrength HighStrength 5%A1.lc1.Vol 5%A1.lc2.Vol 5%2A.lc6.Vol 7%A1.lc5.Vol 7%A1.lc8.Vol

Spirit Nip 40% A1lc. Vol 30ml

High Strength Spirit Nip 40% Alc. Vol

1

250ml Full Strength Pre-mix Spirits 5% A1lc. Vol

250ml
* Ready-Ftou-llDSritnrekngth Pre-mix Spirits

5% Alc. Vol

Bottle of Spirits 40% 2A2lc. Vol 700ml

High Strength Bottle of Spirits 40% Alc. Vol

1.2

300ml Full Strength Pre-mix Spirits 5% A1.lc2. Vol

300ml Full Strength Pre-mix Spirits 5% Alc. Vol

7%Alc.Vol

275ml Full Strength RTD* 5% Alc. Vol

1.5

375ml Full Strength Pre-mix Spirits 5% A1.lc5. Vol

375ml Full Strength Pre-mix Spirits 5% Alc. Vol

7%1.410%A1lc..9Vol 7% 1A.lc6. Vol

660ml High Strength RTD* 7% Alc. Vol

2.4

440ml High Strength Pre-mix Spirits 7% 2A.lc4. Vol

440ml High Strength Pre-mix Spirits 7% Alc. Vol

1.2

330ml Full Strength RTD* 5% Alc. Vol

1.7

440ml Full Strength Pre-mix Spirits 5% A1.lc7. Vol

440ml Full Strength Pre-mix Spirits 5% Alc. Vol

2.6

660ml Full Strength RTD* 5% Alc. Vol

1.4 – 1.9

250ml High Strength Pre-mix Spirits

1.5

275ml High Strength RTD* 7% Alc. Vol

1.6

300ml High Strength Pre-mix Spirits

1.8

330ml High Strength RTD* 7% Alc. Vol

2.1

375ml High Strength Pre-mix Spirits 7% A2l.c1. Vol

375ml High Strength Pre-mix Spirits 7% Alc. Vol

3.6

660ml

High Strength

330ml Full Strength RTD*

660ml Full Strength RTD*

275ml High Strength RTD*

330ml High Strength RTD*

RTD*

3.6

       

250ml High Strength Pre-mix Spirits

300ml High Strength Pre-mix Spirits

7% – 10% Alc. Vol 7% Alc. Vol

STRESS

11 10 9 8 7 6 5 4 3 2

1 1 in 100

0

Guideline 1: Reducing the risk of alcohol-related harm over a lifetime

Men Women

                                    

1 2 3 4 5 6 7 8 9 10 Standard drinks

Lifetime risk of death from alcohol-related disease per 100 drinkers, by number of

figure 5 lifetime risk of death from alcohol-related disease per 100 drinkers, by number

of standard drinks per occasion, australia 2002

standard drinks per occasion, Australia 2002

Source: Rehm et al (2008)

For people who regularly drink 2 standard drinks per day, the lifetime risk of

death from an alcohol-related disease is about 0.4 in 100 people with that

for people who regularly drink two standard drinks per day, the lifetime risk of death from

drinking pattern. Above that level, the risk increases with the number of drinks

an alcohol-related disease is about 0.4 in 100 people with that drinking pattern. above that perday,anldeveisl,tahebroisvkeinc1reianses1w0i0thathte3nudmrbienrkosfdprienkrsdpearyd.aTy,ahnedirsiasbkovien1cirne1a0s0easttmhreoeresharply

drinks per day. the risk increases more sharply for women than for men.

for women than for men.

Source: National Health and Medical Research Council Australian Guidelines to Reduce Health Risks from Drinking Alcohol, Canberra: Commonwealth of Australia, 2009.

alcohol-related injury

The problem with caffeine and stress

Basis and quality of the evidence

Lifetime risk of death from alcohol-related injury

Caffeine is a substance that is derived from plants or is produced

A modelled analysis (Rehm et al 2008) was used to determine the

synthetically, and is an additive in a number of food products and

accumulated lifetime risk of death from injury categories for which alcohol

over-the-counter medications such as pain relievers, appetite

has an accepted causal effect (based on established epidemiological data:

English et al 1995; Rothman & Greenland 1998). Lifetime risk was calculated suppressfaornatnsi,nacrneadsincgonludmbmereofddircininksepse.rMoccoasiotncaondmfomr voarnioluys,niutmisberksnofown to

drinking occasions over a lifetime. Alcohol-attributable injury deaths per

be an ingredient in tea, coffee, chocolate, cocoa, colas, and

7 drinking occasion, and lifetime risk, were calculated using four main steps:

so-called•‘ecnalceurlagtiyon-bofooovesrtalilnggen’ dbere- vanedraggee-spse.ci c risk of fatal injury per day for each category of injury without the impact of alcohol (ie baseline risk)

Tea and coffee are seen by most people merely as beverages,

when in fact, they are actually vehicles for the psychoactive drug caffeine. Because caffeine is a central nervous system stimulant,

7 Details of the modelling are given in Appendix A5.

in anxious people, it can worsen the symptoms of stress

considerably.

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al h

e

a

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a

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ouncil |

43

People experiencing stress would do well to eliminate caffeine from their diet – or at least reduce their intake to a nominal amount. For tea and coffee drinkers, it is now possible to purchase these products in caffeine-reduced and decaffeinated forms. For people accustomed to a high caffeine intake, it is advisable to reduce consumption gradually to minimise potential withdrawal effects.

213

Lifetime risk per 100 drinkers

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Making Healthy Choices

When people are stressed, it is often the simple things that are overlooked. And yet, it is the simple things that can often make the most difference to the level of stress we experience. Some of the following ideas may prove helpful.

Regular daily exercise

When we experience stress, our body produces the hormone adrenaline (part of the ‘ ght or ight’ response). Left unused, adrenaline leaves us feeling ‘wound up’ or ‘on edge,’ our blood pressure will remain higher, and we will nd it dif cult to relax. Exercise can burn off this stress hormone, enabling us to relax.

The best kind of physical activity is separate from work, and dedicated purely to your physical and mental health. Walking, cycling, or using an exercise machine – even if for only 20 minutes several times a week, or when feeling stressed, can be quite bene cial.

As well as exercise, consider scheduling other pleasant activities. See section on Activity Planning (page 24).

Strengthen your relationships

Ironically, it is often when people are most stressed and need the support and stability of relationships, that they most neglect them.

Make it a priority to put quality time into strengthening and nurturing your relationships (with partner, friends, relatives, children). Make an extra effort to spend time with friends – particularly if they are in similar circumstances. You may be able to exchange helpful ideas,‘get things off your chest,’ and feel less isolated and overwhelmed.

  

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214

Find a positive way of ‘letting off steam’

If you need to ‘let off steam,’ do it away from family or friends. Anger is very useful, if it is used for problem-solving, but it is destructive if we turn it on ourselves or others.

Make room for difference

Make room for difference in the way you and your partner see things, and especially in the way you deal with your feelings. Don’t let stress exaggerate differences or make minor con icts into issues that feel much bigger than they are.

Learn to say “no”

For people experiencing stress, it is often important to learn
to say “no” (without feeling guilty) to new commitments or potentially stressful additional tasks or responsibilities. Say “yes” only to things you can achieve realistically.

Find a retreat where you can ‘clear your head’

Find a place where you can go and be undisturbed, where you’re able to feel calm, settled, and separated from the things that seem to be causing your stress. A place where, even if for only an hour, you can slow down and allow your body and mind to rest.

Re ect on what you value most

All of us would likely bene t from regularly stopping to consider what is really most important to us – what we value most. Too often, we can nd that all our energy is taken up with things that are quite secondary to what is most important to us. For example, we can neglect our health and relationships because we allow other demands or priorities to ‘jump the queue,’ or overshadow everything else.

215

STRESS

Relationship Violence

217

Relationship Violence

Tickþthe signs that are familiar Physical Violence

r Pushing, shoving
r Punching, biting, scratching, kicking, slapping
r Holding roughly, shaking, restraining
r Torturing, burning
rThrowing or smashing a partner’s personal objects rHurting or killing a partner’s pet
rThreateningly punching holes in a wall or door
r Throwing objects as weapons, such as dishes, glasses,

ornaments, or other objects, that could do harm
r Threatening to use – or using – a weapon, such as a gun, knife,

scissors, pan, shoe, or bottle, to hurt a partner
r Driving a vehicle, with a partner as a passenger, too fast or

recklessly, to cause fear or to intimidate

Emotional and Verbal Violence

rHurtful put-downs or name-calling
rHumiliating or shaming a partner
r Playing nasty, manipulative, or hurtful mind-games
rMaking a partner frightened
rConstant nagging or needling
rMaking a partner always feel bad about him or herself rDisclosing embarrassing or private things about a partner in

public, without your partner’s consent
rBeing very controlling or manipulative
r Using superior verbal skills to confuse, override, or intimidate

a partner
rInvolving/using children to manipulate or hurt a partner

218

  

RELATIONSHIP VIOLENCE

Social Violence

rNot allowing a partner to choose his/her own friends rOften speaking badly about a partner’s family or friends rIntentionally making a partner’s family or friends feel

unwelcome
r Humiliating, shaming, or belittling a partner in public
r Controlling a partner’s every move; always checking-up on

him/her; not allowing him/her to go out when he/she chooses

Financial Violence

rNot allowing a partner to have money
r Selling a partner’s property, or property owned together,

without his/her knowledge or permission
r Knowingly exploiting, manipulating, or taking advantage of a

partner nancially
r Making a partner beg, or behave in a manner against his/her

will, for money
rControlling or using a partner’s nances (or nances held in

common) against his/her will
r Shaming, belittling, or humiliating a partner because of his/her

limited capacity to earn income

Religious Violence

rTrying to make a partner feel inferior or guilty because he/she doesn’t, or doesn’t want to, share the same beliefs

r Making a partner feel unsafe, frightened, inferior, humiliated, or personally compromised, by coercing him/her to participate in certain religious gatherings, rituals or ceremonies

r Using religious ideas, beliefs, threats, manipulation, or mind- games, to control a partner, exploit a partner sexually or nancially, or cause him/her signi cant guilt, fear, or anxiety

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RELATIONSHIP VIOLENCE

Sexual Violence

rForcing a partner to have sex against his/her will
rBeing intentionally dishonest about the use of contraception rUsing drugs or alcohol in order to exploit a partner sexually rIntentionally humiliating a partner sexually
rUsing an object to violate a partner sexually
rSaying or insinuating hurtful or humiliating things about a

partner’s genitals or sexual performance – especially in the hearing of others

If some of these signs are familiar and you are concerned about your behaviour or the behaviour of your partner –

     

RELATIONSHIP VIOLENCE

220

Speak to someone you trust, who can support you in thinking through what to do.

.TAKE ACTIon.

Speak to your doctor

Phone a 24 hour Domestic Violence Help Line (see the front of your local telephone directory).

About Relationship Violence

Relationship violence is behaviour that violates, hurts, harms, humiliates, threatens, shames, manipulates, belittles, or frightens another person.

Both women and men sometimes resort to violence. Whoever uses it, is responsible for their own behaviour, for stopping their violence and, if need be, for obtaining professional assistance and support in order to stop it.

Whatever a partner’s behaviour may be like – even if violent – it will not be resolved through a violent response. If a person’s behaviour is hurtful, infuriating, or destructive to the relationship, then these issues and perhaps the future of the relationship

need to be given honest consideration (which might require
a lot of courage and some hard decisions). Ceasing violence should never be dependent on an expected change in a partner’s behaviour. It needs to stop because it will achieve only harm, and will diminish very rapidly any chance of the relationship being salvaged.

Relationship violence, whether it’s the behaviour of women or men, can be substituted with behaviours, strategies and skills that make room for tempers to calm, for issues to be tackled rationally, reasonably, and constructively – creating hope for the relationship rather than despair.

Relationship violence is often a sign that a relationship is heading into serious trouble and that problems exist that will very likely not be resolved without appropriate professional support and assistance. Once it is occurring, relationship violence usually worsens and becomes habitual.

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RELATIONSHIP VIOLENCE

Although there are some clear criteria for identifying relationship violence (such as physical or sexual assault, psychological trauma, or nancial deprivation), what women or men experience
as violating needs to be taken seriously and considered

carefully. Furthermore, the simplistic distinction (still made in much literature on relationship violence) between victim and perpetrator is much less helpful than taking all the facts of a situation into consideration.

Making this distinction serves only to make matters worse, particularly in cases where both partners have used some form of violence. By distorting the reality of what has been happening, it is likely that the kind of solutions applied to the problem will be unfair (inequitable), inappropriate, and destructive, rather than helpful to the future of the relationship.

In circumstances of signi cant or persistent violence, partners may need to be separated, or one partner helped to stay in alternative safe accommodation, while sense is made of what has been happening, and genuinely helpful options for support and assistance are considered.

Feeling unsafe or that things are unsafe for children should
never be ignored.This is especially the case where people are geographically isolated. If the situation becomes worse, there may not be enough time to prevent something bad happening, because of the distance someone must travel to get or give help.

 

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222

How to help someone else

You may know of a relationship in which violence is occurring, but don’t know what to do. There are several things to keep in mind here:

• Think about how you could help (and what you might need to do) that won’t create a risk for your safety.

• Don’t offer to help unless you are prepared for a potentially frustrating, confusing and draining situation.

• Think about who could give you extra support while you’re helping others.
Ways of helping

• Express clearly your concern about what is happening.

• Avoid imposing your own view or opinions about what
they should do.

• Help them understand and take the violence seriously; including what it might mean for their relationship if it continues (remember relationship violence often worsens and becomes habitual).

• Be a good listener and avoid being impatient (even if little progress seems to be made).

• Be encouraging and supportive, but avoid being critical of the other partner.

• Help them to understand that it is not a betrayal, cowardly, or weak to take measures to stop the violence. It puts
a value on their relationship and on themselves to take action, even if to do so is at rst embarrassing, upsetting, or hard.

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RELATIONSHIP VIOLENCE

• Be sure to consider carefully their safety and your own. If need be, draw up a safety plan.

• Help them to obtain the very best professional support and assistance available. Perhaps offer to go with them to see a counsellor, or speak to a doctor or the police.

• Offer to help obtain any information that may be needed by them, to be able to make sound, well-informed decisions about things.

• Don’t take over; don’t pressure them into decisions; don’t do things without their consent.

• If the situation is becoming unsafe, is immediately unsafe, or is feeling unsafe, encourage them to contact the police (or offer to do so yourself). If using some other means of achieving safety (such as arranging for a friend to come and take them to safety, or driving themselves to a safe place), ensure that risks are properly considered and assessed before doing so.

 

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224

Alcohol

Information in this chapter provided in association with the Australian Drug Foundation

Signs of a problem with Alcohol

Tickþthe signs that are familiar
r Using alcohol to cope with stress, anxiety, anger, or

sleeplessness

rRegularly drinking more than 4 drinks on one occasion

rHave tried to cut down or stop drinking without success

rSometimes fail to do what is normally expected of you because of drinking

r Feeling uneasy, guilty, or remorseful about the amount of alcohol being consumed

r Feeling especially hopeless, angry or sad, following a bout of drinking

rBehaviour after a bout of drinking that is later regretted rHave been injured (or have injured someone else) as a result

of drinking

rDrinking is followed by con ict or arguments with a partner

rBeing unable to stop drinking once having started

r A friend, relative, or a doctor has expressed concerns

rUnable to remember what happened the night before because of drinking

r Sometimes start drinking early in the day as a way of ‘steadying the nerves,’ or getting rid of a hangover

  

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226

READ:

About Alcohol and, Doing Something About It, to consider your options and to decide
what to do.

VISIT:

Druginfo Clearinghouse

http://www.druginfo.adf.org.au/ or call 1300 85 85 84

Counsellingonline:

http://www.counsellingonline.org.au On this site, you can communicate with a professional counsellor about an alcohol or drug-related concern.

Speak to a doctor
OR
Phone State and Territory Alcohol and Drug Services

[Note: Most 1300 and 1800 numbers cannot be accessed outside the states or territories
in which they are based]

ACT (02) 6207 9977 QLD 1800 177 833 nSW 1800 422 599

(02) 9361 8000 nT 1800 131 350

SA 1300 131 340 or (08) 8363 8618

VIC 1800 888 236 TAS 1800 811 994 WA 1800 198 024

(08) 9442 5000

If some of these signs are familiar –

.TAKE ACTIon.

    

For more information, see Fact sheet 9 Reducing alcohol and other drugs at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

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ALCOHOL

About Alcohol

Alcohol use is a widely-accepted part of Australian culture. It is the most commonly used mood-changing recreational drug, with over 40% of Australians aged 14 years and older drinking alcohol at least once a week.

Drinking can be part of an enjoyable and healthy lifestyle that includes good diet and exercise. However, alcohol is a drug and the misuse of alcohol is one of the chief causes of preventable death in Australia.While there is no safe level of drinking, the National Health and Medical Research Council has developed a set of guidelines to help people make choices about how much they drink and the potential risks to their health.

Alcohol is a depressant drug

Alcohol is actually a central nervous system depressant and not a stimulant as popularly believed. It slows the activity of the central nervous system, affecting concentration and coordination, and slowing the response time to unexpected situations.

In small doses, alcohol produces relaxation, a lowering of inhibitions, feelings of con dence, and more ‘outgoingness’. In larger doses, alcohol can cause unconsciousness and death.

The effects alcohol can have on health and well-being

Drinking too much alcohol on a regular basis can affect a person’s health and well-being in a range of ways.The effects of alcohol can also vary depending on a range of factors such as:

• age

• body size

• how recently you have eaten

   

ALCOHOL

228

• medications you are taking

• whether you are a man or a woman

• level of tness

• health of your liver.
Some of the immediate or short-term ways alcohol affects health and well-being include:

• Reduced coordination, slower re exes and poor muscle control which may increase your risk of falling or having an accident

• Reduced inhibition, more intense moods and impaired judgement which may mean that people might react uncharacteristically or get involved in situations in which they wouldn’t normally become involved (i.e. ghts)

• Dif culty concentrating and memory disturbance

• Disturbed sleep

• Sexual dysfunction

• Worsened depression, anxiety, and chronic stress

• Nausea and vomiting

• Coma and death. Long-term effects can include:

• Liver disease, including swelling and pain, cirrhosis and cancer

• Brain damage and memory loss

• Cancer, including breast, mouth, throat, and oesophagus
cancers

• Worsened depression, anxiety, and chronic stress

• Heart and circulatory problems, including high blood pressure

• Stomach, bowel and pancreas problems, including in ammation, bleeding and ulcers

• Alcohol dependence.

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ALCOHOL

The bene ts of alcohol on health

There is some evidence to suggest that, for middle-aged and older people, there are health bene ts to be had from drinking regularly very small amounts of alcohol (within Guideline 1). However, the bene ts that regular drinking of a small amount of alcohol might have on cardiovascular disorders can also

be achieved through a healthy diet, regular exercise, and not smoking.

Reducing alcohol related risks and harms

The Australian Guidelines to Reduce Health Risks from Drinking Alcohol provide 4 guidelines for people to reduce the risk of harm associated with drinking alcohol.

Guideline 1:
Reducing the risk of alcohol-related harm over a lifetime

The lifetime risk of harm from drinking alcohol increases with the amount of alcohol consumed.

For healthy men and women, drinking no more than 2 standard drinks on any day reduces the lifetime risk of harm from an alcohol-related disease or injury.

If this guideline is followed, the lifetime risk of death from alcohol-related disease or injury for both men and women remains below 1 in 100. Every drink above this level increases this lifetime risk of both disease and injury and drinking less on each occasion reduces the risk.

  

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230

11 10 9 8 7 6 5 4 3 2 1 0

Lfiifgeutirmee5riskloifedtiemaethrifsrkomofadlceoahthol-freolamteadlcdoihseoal-srelpaeterd10d0isedarsinekpeersr,1b0y0nudmrinbkeerrosf, by number standard drinokf stpaenrdoacrdcadsiroink, sApuestrraolciaca2s0io0n2, australia 2002

FSourrcpee: oRpehlemweht aol (r2e0g0u8la)rly drink 2 standard drinks per day, the lifetime risk of

death from an alcohol-related disease is about 0.4 in 100 people with that

drinking pattern. Above that level, the risk increases with the number of drinks

Men Women

1 in 100

 

             

1 2 3 4 5 6 7 8 9 10 Standard drinks

per day, and is above 1 in 100 at 3 drinks per day. The risk increases more sharply

for people who regularly drink two standard drinks per day, the lifetime risk of death from

for women than for men.

an alcohol-related disease is about 0.4 in 100 people with that drinking pattern. above that

Source: National Health and Medical Research Council Australian Guidelines to Reduce Health Risks

level, the risk increases with the number of drinks per day, and is above 1 in 100 at three

from Drinking Alcohol, Canberra: Commonwealth of Australia, 2009.

drinks per day. the risk increases more sharply for women than for men.

Guideline 2:

Raeldcuochinogl-threlraitsekdofininjjuryon a single occasion of drinking Basis and quality of the evidence

On a single occasion of drinking, the risk of alcohol-related injury increases with the amount consumed.

Lifetime risk of death from alcohol-related injury

A modelled analysis (Rehm et al 2008) was used to determine the

For healthy men and women, drinking no more than 4

accumulated lifetime risk of death from injury categories for which alcohol has an accepted causal effect (based on established epidemiological data:

standard drinks on a single occasion reduces the risk of

English et al 1995; Rothman & Greenland 1998). Lifetime risk was calculated

alcohol-related injury arising from that occasion.

for an increasing number of drinks per occasion and for various numbers of drinking occasions over a lifetime. Alcohol-attributable injury deaths per

Drinking 4 standard drinks on a single occasion more than doubles the relative risk of injury in the 6 hours afterwards.This

7 drinking occasion, and lifetime risk, were calculated using four main steps:

• calculation of overall gender- and age-speci c risk of fatal injury per day

risk increases rapidly when more than 4 drinks are consumed.

for each category of injury without the impact of alcohol (ie baseline risk)

Each drinking occasion also contributes to the lifetime risk of

alcohol-related harm (see Guideline 1, page 230).

7 Details of the modelling are given in Appendix A5.

national health and medical research council |

231

Lifetime risk per 100 drinkers

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Guideline 3:

Children and young people under 18 years of age

For children and young people under 18 years of age, not drinking alcohol is the safest option.

Parents and carers are advised that children under 15 years of age are at the greatest risk of harm from drinking and that for this age group, not drinking is especially important.

For young people aged 1517 years, the safest option is to delay the initiation of drinking for as long as possible.

Guideline 4:

Pregnancy and breastfeeding

Maternal alcohol consumption can harm the developing fetus or breastfeeding baby.

For women who are pregnant or planning a pregnancy, not drinking is the safest option.

For women who are breastfeeding, not drinking is the safest option.

These guidelines provide a general guide and there are a number of additional issues to take into account when thinking about your drinking. For example:

Not drinking is the safest option when involved in, or supervising, any activity involving risk or a degree of skill, such as:

• driving

• ying

• skiing

• water sports

• using heavy machinery, farm machinery, or power tools

• supervising children.

 

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232

Some people should get advice about drinking because of possible interactions and harmful effects.This includes people who:

• are taking medications (including over-the-counter or prescription medications)

• have alcohol-related, or other physical, conditions that can be made worse or affected by alcohol

• people with mental health conditions.
Some groups should be aware that they can be at increased risk
of harm if they drink.This includes:

• young adults aged 18−25 years

• older people aged over 60 years

• people with a family history of alcohol dependence

• people who use drugs illicitly.
What is a standard drink?
The amount of alcohol in alcoholic drinks varies. A standard drink is de ned as one that contains 10 grams of pure alcohol.

NUMBER OF STANDARD DRINKS – BEER

        

1.1

285ml
Full Strength 4.8% Alc. Vol

0.8

285ml Mid Strength 3.5% Alc. Vol

0.6

285ml Low Strength 2.7% Alc. Vol

1.6

425ml
Full Strength 4.8% Alc. Vol

1.2

425ml Mid Strength 3.5% Alc. Vol

34

24 x 375ml

Full Strength 4.8% Alc. Vol

0.9

425ml Low Strength 2.7% Alc. Vol

24 x 375ml Mid Strength 3.5% Alc. Vol

1.4

375ml
Full Strength 4.8% Alc. Vol

24

1

375ml Mid Strength 3.5% Alc. Vol

0.8

375ml Low Strength 2.7% Alc. Vol

     

1.4 1 0.8

19

24 x 375ml Low Strength 2.7% Alc. Vol

375ml
Full Strength 4.8% Alc. Vol

375ml Mid Strength 3.5% Alc. Vol

375ml Low Strength 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE 233

ALCOHOL

1.4 1 0.8

375ml 375ml 375ml

34

24

19

1.4 1 0.8

24 x 375ml

24 x 375ml

24 x 375ml

Full Strength

Mid Strength

Low Strength

34

24

19

375ml 4.8% Alc. Vol

375ml 3.5% Alc. Vol

375ml 2.7% Alc. Vol

Full Strength

Mid Strength

Low Strength

Full Strength 4.8% Alc. Vol

Mid Strength 3.5% Alc. Vol

Low Strength 2.7% Alc. Vol

24 x 375ml 4.8% Alc. Vol

24 x 375ml 3.5% Alc. Vol

24 x 375ml 2.7% Alc. Vol

13.5% Alc. Vol

13.5% Alc. Vol 13.5% Alc. Vol 12.5% Alc. Vol 12.5% Alc. Vol 12.5% Alc. Vol

NUMBER OF STANDARD DRINKS – SPIRITS

17.5% Alc. Vol

* Ready-to-Drink

Full Strength 4.8% Alc. Vol

Mid Strength 3.5% Alc. Vol

Low Strength 2.7% Alc. Vol

NUMBER OF STANDARD DRINKS – WINE

How do you line up against these guidelines?

234

• If you are drinking within the recommended guidelines, you are reducing the risk of experiencing alcohol-related harm.

• If you are drinking more than is recommended by the guidelines, read on to consider how to reduce your drinking and the risk of experiencing alcohol-related harms.

NUMBER OF STANDARD DRINKS – WINE

      

1.6 1 0.9 1.4 1

150ml 100ml 60ml 150ml

1.6 1 0.9 1.4 1

1.4

Average

Standard Serve

Standard Serve

Average

Standard Serve

150ml Restaurant Serving

100ml
of Red Wine

60ml of Port

150ml Restaurant Serving

100ml
of White Wine

7.5

Average of Red Wine

Standard Serve 13.5% Alc. Vol

Standard Serve 18% Alc. Vol

Average
of White Wine

150ml 11.5% Alc. Vol 1.4

Restaurant Serving 13.5% Alc. Vol

of Red Wine 13.5% Alc. Vol

of Port 18% Alc. Vol

Restaurant Serving 11.5% Alc. Vol

150ml
Serve of Champagne

7.5

of Red Wine 13.5% Alc. Vol

of White Wine 11.5% Alc. Vol

Average Restaurant 12% Alc. Vol

Bottle of Champagne

100ml

Standard Serve of White Wine 11.5% Alc. Vol

Average Restaurant

750ml

 

Serve of Champagne 12% Alc. Vol

750ml 12.5% Alc. Vol

Bottle of Champagne 12.5% Alc. Vol

    

8 43 21 7.5 39 19.5 28

750ml 4 Litres 2 Litres 750ml

8 43 21 7.5 39 19.5 28

Bottle of Red Wine Cask Red Wine Cask Red Wine Bottle of White Wine Cask White Wine Cask White Wine Cask of Port

750ml 4 Litres 2 Litres 750ml 4 Litres 2 Litres 2 Litres 13.5% Alc. Vol 13.5% Alc. Vol 13.5% Alc. Vol 12.5% Alc. Vol 12.5% Alc. Vol 12.5% Alc. Vol 17.5% Alc. Vol

Bottle of Red Wine Cask Red Wine Cask Red Wine Bottle of White Wine Cask White Wine Cask White Wine Cask of Port

4 Litres 2 Litres 2 Litres

NUMBER OF STANDARD DRINKS – SPIRITS

       

1

22

1.1

1.2

2.6

1.5

1.8

3.6

30ml

700ml

275ml RTD*

330ml RTD*

660ml RTD*

275ml RTD*

330ml RTD*

660ml RTD*

1

22

Full Strength 5% Alc. Vol

Full Strength 5% Alc. Vol

Full Strength 5% Alc. Vol

High Strength 7% Alc. Vol

High Strength 7% Alc. Vol

High Strength 7% Alc. Vol

High Strength

High Strength

30ml Spirit Nip

700ml Bottle of Spirits

RTD* 5% Alc. Vol

RTD* 5% Alc. Vol

RTD* 5% Alc. Vol

RTD* 7% Alc. Vol

RTD* 7% Alc. Vol

RTD* 7% Alc. Vol

High Strength 40% Alc. Vol

High Strength 40% Alc. Vol

Spirit Nip 40% Alc. Vol

Bottle of Spirits 40% Alc. Vol

1.1

1.2

2.6

1.5

1.8

3.6

275ml

330ml

660ml

275ml

330ml

660ml

Full Strength

Full Strength

Full Strength

High Strength

High Strength

High Strength

       

1

1.2

1.5

1.7

1.4 – 1.9

1.6

2.1

2.4

250ml

300ml

375ml

440ml

250ml

300ml

375ml

440ml

1

1.2

1.5

1.7

1.4 – 1.9

1.6

2.1

2.4

Full Strength

Full Strength

Full Strength

Full Strength

High Strength

High Strength

High Strength

High Strength

250ml Pre-mix Spirits

300ml Pre-mix Spirits

375ml Pre-mix Spirits

440ml Pre-mix Spirits

250ml Pre-mix Spirits

300ml Pre-mix Spirits

375ml Pre-mix Spirits

440ml Pre-mix Spirits

Full Strength 5% Alc. Vol

Full Strength 5% Alc. Vol

Full Strength 5% Alc. Vol

Full Strength 5% Alc. Vol

High Strength 7% – 10% Alc. Vol

High Strength 7% Alc. Vol

High Strength 7% Alc. Vol

High Strength 7% Alc. Vol

Pre-mix Spirits

Pre-mix Spirits 5% Alc. Vol

Pre-mix Spirits 5% Alc. Vol

Pre-mix Spirits 5% Alc. Vol

Pre-mix Spirits 7% – 10% Alc. Vol

Pre-mix Spirits 7% Alc. Vol

Pre-mix Spirits 7% Alc. Vol

Pre-mix Spirits 7% Alc. Vol

5% Alc. Vol * Ready-to-Drink

ALCOHOL

‘To numb depression and anxiety

I drink. But the awful sadness

never goes away.’

                     

Over two million Australians live with depression, anxiety and associated drug and alcohol problems. Drinking and taking drugs may numb these feelings at first, but in the long run it just makes things worse. The sooner you get the right treatment, the sooner you’ll recover.

To find out more visit our website or call the infoline. http://www.beyondblue.org.au

         

Some common questions about alcohol

1. Does drinking affect sexual performance?
Yes. Heavy drinking can cause sexual dysfunction. Most men are

aware of the link between alcohol and erectile problems.

2. Is beer fattening?

Yes. Alcohol is high in calories and contains few nutrients or vitamins. Drinking beer, or any other alcoholic drink, adds calories to a person’s diet which can result in a person gaining weight and lead to obesity.

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ALCOHOL

3. Can I save up my drinks for one good session?

No. Drinking more than 4 standard drinks on a single occasion more than doubles the relative risk of experiencing an injury in the following 6 hours (see Guideline 2, page 231). Some of the potential immediate health and well-being risks are outlined on page 228 and 229.

4. Can I drink when I’m on medication?

Mixing alcohol with medications (either over-the-counter or prescription) can have unexpected and even dangerous effects. There is also the risk that alcohol may affect how well the medication works.

It is important to read the packaging and consumer medicines information sheet and to talk to your doctor or pharmacist about the potential effects alcohol and other drugs may have on your medication.

5. Can alcohol help sleep?
No.Though alcohol may help you to feel tired and to go to sleep,

it usually causes disrupted and poor quality sleep.

6. How does alcohol affect mental health conditions?

The relationship between alcohol and mental health conditions is complex. As a general rule, they do not mix well. Alcohol can interfere with the effectiveness of many medications and can be dangerous when taken in combination with others.

Alcohol may even increase the risk of conditions such as depression and anxiety in some people. It may also worsen, rather than help, symptoms and can increase the risk of violence and suicidal behaviour.

7. Should pregnant women drink alcohol?

The World Health Organization and the Australian Guidelines to Reduce Health Risks from Drinking Alcohol note that there is no known safe level of drinking alcohol during pregnancy and breastfeeding.

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ALCOHOL

The safest option for women who are pregnant or planning a pregnancy is not to drink alcohol.

8. Should women who are breastfeeding avoid alcohol?

As mentioned above, there is no known safe level of drinking alcohol while breastfeeding.Therefore, the safest option for women who are breastfeeding is not to drink alcohol.

9. Am I at risk of developing an alcohol-related problem if my family has a history of alcohol problems?

Yes. This does not mean you will develop an alcohol-related problem, but having a family history of alcohol-related problems is one of the factors that increase the risk.

The degree of risk is related to:

• the closeness of the relative who has the alcohol-related problem

• the number of relatives involved.
Knowing your family’s health history can help you understand and make informed choices about your drinking and the potential risks.
10. Can you drink the same amount as you get older?
The older you get, the less well your body can ‘handle’ alcohol. Changes in the body’s makeup and metabolism and increased use of medications as we age, affects the way older people process alcohol. Alcohol can increase the risk of falls, accidents while driving, and suicide in older people. Some medications, when used in combination with alcohol, can also further increase these risks as well as reduce the effectiveness or increase the side-effects of the medications.

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Continue Present Drinking Pattern

Positives

Negatives

A couple of drinks helps me feel comfortable when out and meeting new people

Takes a while to recover the next day from hangover

Change Present Drinking Pattern

Positives

Negatives

Not arguing about alcohol with partner

Not being able to have a couple of drinks after work with mates

Doing Something About It

Now that you know your risk level (and the issues for your health at that level), you can decide to:

• continue as you are OR

• reduce your drinking by either drinking less or
stopping altogether.
Before you decide, consider the positives and negatives using the Balance Sheet:

 

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On balance, do you think you need to do something about your drinking?

NOr YESr Read On….

Cutting down or cutting out?

So, at this stage you know your risk category and have decided to do something about your drinking levels. Your next decision is whether you’ll drink less – or cut out alcohol altogether.

To help you make up your mind, think about the following questions:

r Do you have any health problems that might be made worse by alcohol? Your doctor can advise you.

r Have you solved your drinking problems before by stopping completely? Then this might be your best way now.

r Are you convinced you will never be able to drink sensibly and safely? Cutting out could be your answer.

r Once you start drinking, do you have dif culty stopping? Cutting out could be your answer.

It is a good idea to have a chat to your doctor about your drinking. Doctors can provide advice, information, assistance
and support.They can also help you cope with any withdrawal symptoms you might experience and if required, discuss different treatment options and provide referrals to other services.

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Cutting Down

Positives

Negatives

Can still have the occasional drink with friends?

Not sure I can stop once I start

Cutting out

Positives

Negatives

No risk of losing track of how much I have drunk

People will laugh at me and think I’m strange for not drinking anything

Consider the positives and negatives of cutting down or cutting out alcohol using the Balance Sheet:

What is your decision?

r To cut down your drinking?
r To cut out drinking for a while? r To cut out drinking entirely?

What you decide here might not be the decision you follow for the rest of your life.You can review your drinking goal whenever you want to.

Whatever you decide, con de in the person you are closest to, tell him/her your goal, and get his/her support.

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If you need professional assistance to help you choose the best goal, speak to your doctor, or contact one of the following alcohol and drug information services:
[Note: Most 1300 and 1800 numbers cannot be accessed outside the states or territories in which they are based]

ACT (02) 6207 9977 QLD 1800 177 833 nSW 1800 422 599

(02) 9361 8000 (metro area) nT 1800 131 350

SA 1300 131 340 (08) 8363 8618

VIC 1800 888 236 TAS 1800 811 994 WA 1800 198 024

(08) 9442 5000 (metro area)

For information, call the Druginfo Clearinghouse on 1300 85 85 84

Cutting out alcohol for a while

People decide to cut out alcohol for different reasons, and
they often have different long-term goals. Some people want
to stop drinking forever; others just need a break from it. No matter what your reasons or what your long-term goals are, the main job ahead of you now is to focus on your goals and work towards achieving them.

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Will I experience withdrawal if I stop drinking?

If you are a heavy drinker and you are dependent on alcohol, you may experience withdrawal if you stop drinking suddenly.

Mild withdrawal symptoms may include:

• nausea

• loss of appetite

• sweating

• restlessness, agitation and irritability

• the ‘shakes’

• poor sleep.
Severe withdrawal symptoms may include:

• vomiting

• fever

• disorientation

• hallucinations

• having ts

• coma (with a small risk of death if not treated with medication).
People who experience severe withdrawal symptoms should consult their doctor immediately.
Very Important..
If you are a heavy drinker or you are dependent on alcohol, speak to a doctor or health professional at an Alcohol and Drug Service, before you start cutting out alcohol. Supervised withdrawal may be necessary.

 

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Make a contract with yourself

If you have decided to cut down or cut out drinking, why not make a contract with yourself? You can also show it to a close friend, partner, or family member who can help remind you of the contract and why you are changing your drinking patterns if things get tough.

MY ConTRACT Cutting Down or Cutting out

I can make decisions that affect my lifestyle and well-being I will stop drinking entirely from……./……/20…
oR
I will stop drinking for a period of……weeks starting from……./……/20…
AnD/oR
From……./……/20… I will cut down drinking and drink no more than ……..a day/week/etc

Planning ahead to minimise failure

If you can identify the occasions where you drank more than you meant to, or badly wanted a drink, it will help you to plan ahead to minimise or avoid the chances of you drinking or drinking more than you planned.

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Think about the situations in which you are at highest risk of drinking?

For example:

• Are your high-risk situations in particular places (like home)? Or around certain people; certain family members? Or at particular times, like after dinner?

• Are high-risk situations also tied to certain emotions – when you feel depressed, angry, irritable, on edge, worried, guilty?

• Think of the last few times when your drinking got you into trouble… and when it didn’t. What is the difference between these occasions?
Some examples of risky situations may include:

• when I have had a row with someone in the family

• when someone has been having a go at me and I feel like a
failure

• when I am out at the pub and I feel uncomfortable if I’m sober.
Everyone is unique and has different risky situations. Perhaps you could think of your own high-risk situations and write them down.
My main high-risk situations are:
1 …………………………………………………………………………………. 2 …………………………………………………………………………………. 3 …………………………………………………………………………………. 4 ………………………………………………………………………………….
Now that you have worked out when and why you might drink
a lot, how could you cope in these situations without a drink in your hand? Instead of waiting until you are under pressure, it is best to plan ahead and prepare some useful strategies for coping.
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In working out some strategies for coping, bear in mind that:

• they need to be well thought-out and realistic

• you may need to be quite creative and think of things you haven’t tried before

• you may need courage to carry them out but, if they are too dif cult or need too much courage, you probably won’t use them.

List your main high-risk situations again, but this time, with some strategies for coping with them.

My main high-risk situations are:

1. When I have had a row with someone in the family

My strategies for coping are:

1. To take the dog for a walk to the park

2.

2.

3.

3.

4.

4.

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Setting your own drinking guidelines

If your drinking goal is to cut out alcohol entirely, your guidelines are clear-cut:

NO ALCOHOL IN ANY SITUATION.
If your goal is cutting down, you will need to set some guidelines

like these:

r how many days a week you’ll be drinking

r how much you’ll have on your drinking days

r how many alcohol-free days you’ll have each week

r high-risk situations where you’ll avoid drinking altogether

r having at least two strategies to deal with high-risk situations

r know who your mates and/or supporters are; the ones you can rely on to help you through.

 

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246

My Drinking Guidelines Are

1. Circle the day(s) I will have as alcohol-free (ideally 2 days a week)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2. My limit of standard drinks on any one drinking day is…………

3. On average I will drink no more than…………standard drinks per day which equals a limit of…………standard drinks per week.

4. My personal goal is …………………………………………………………………..

5. High-risk situations I will avoid altogether are ……………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………

6. Other high-risk situations and strategies for coping are:

High-risk Situations

Strategies for Coping

1.

a.

b.

2.

a.

b.

3.

a.

b.

4.

a.

b.

I will not be hard on myself if I don’t always achieve these goals – but I will keep trying

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Practical Tips for Cutting Down or Cutting Out

• Practise saying:“noTHAnKS.” It may be dif cult at rst, but you will be surprised how quickly it can become comfortable to say “NO”. Others might appreciate it.

If you have always said “YES” in the past, it can be hard to say that rst “NO”. But once you have taken the plunge, you will be pleasantly surprised how easy it becomes to refuse a drink, and you will feel good about yourself too.

A simple “no thanks, I don’t feel like drinking” is effective.

Or you can say……..

“no thanks, I’m cutting down.”
“no thanks, I’m having a rest from drinking for a while.”

“no thanks, I’m taking some medication that means I can’t drink.”

“no thanks, I’m oK for now, but let me buy you one.” “no thanks, I’ve had my limit” or “I’ve had enough.”

If people keep pushing drinks onto you, ask yourself why they are doing it. Maybe they feel more comfortable about their own drinking if you drink like them. If this is a high-risk situation for you, perhaps you need to avoid it.

• Try low-alcohol alternatives. Try the range of low and medium-strength beers, or dilute your wine and/or spirits to make your drinks last longer.

• Eat before or while you are drinking. With food in your stomach, you are likely to drink more slowly and the alcohol is absorbed into your bloodstream at a slower rate.

• Take less alcohol with you. When you go out, you tend to drink what you take with you. Take less and drink less.

  

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• Count your drinks. Remember to maintain your drink diary. Check the label on the bottle or can of alcohol – it will tell you how many standard drinks it contains. If you are drinking stubbies, bottles or cans, put the caps and ring pulls in your pocket so you can keep a count of how many you have drunk.

• Slow down your drinking. You’ll enjoy your drink just as much, maybe more, if you drink it slowly. Sip, don’t gulp. Try to sit on a schooner for about 30 minutes. This will help you control your rate of drinking. Concentrate on drinking every drink slowly.

• Make every second drink a non-alcoholic drink. Drink soft drink, water, or fruit juice as ‘spacers.’ You will nd that by having a drink in your hand, even a soft drink, you won’t feel left out.

• Drink water with a meal. Have water available on the table while you are having a meal.

• Use a smaller glass or add more non-alcoholic mixer. If you normally have a large beer (i.e. a pint), have a small glass and drink it slowly. If you make your own mixed drinks, use less alcohol.

• Avoid top-ups. With top-ups, you can’t be sure how much you are drinking.

• When you are thirsty, have a soft drink or water rst. By quenching your thirst, you will be able to drink your alcohol more slowly.

• Stop drinking when you have reached your limit. Start drinking soft drinks, fruit juice, etc.You’ll nd that you can do without that extra drink after all.

• Avoid drinking in rounds and ‘schools.’ Set your own drinking pace. The following strategies can help you avoid drinking a ‘round’:

− Simply opt out. Say you just don’t want to join the round. 249

ALCOHOL

−  Join the round, but occasionally order a non-alcoholic drink for yourself as a spacer.

−  Buy a round (to show your generosity), but then opt out and buy your own. You may pay a bit more, but you don’t harm your health.

−  Pass up a drink during the round; your friends won’t mind, you’re saving them money.
If the suggestions for drinking in rounds or schools are too dif cult, avoid the situations where the pressure is on you to drink in groups.
Avoid drinking situations. Go to places where they don’t serve alcohol. By choosing to cut down on your drinking, you may need to nd new ways to entertain yourself. If you drink because you are bored or stressed, try taking a walk or calling a friend instead.
Coping with slip-ups
If you do slip-up, it doesn’t have to be the end of your efforts.
Lapses and slip-ups are normal!
The worst thing to do is to blame yourself for being weak or to start thinking you’ve failed. Don’t throw in the towel.You might just have to revise your strategies or your drinking guidelines and continue.
By making these slips, we learn how to avoid future pitfalls; when you lose, don’t lose the lesson! Think about what caused you to slip-up and nd ways of dealing with it in the future. Discuss it with your supporter, your mates, or a health professional. Look at the drinking tips and remind yourself of your reasons for cutting down. Review your determination to succeed.
If you do resume your regular old drinking patterns, don’t despair. Don’t give up your intention to cut down on your drinking. Most people who want to change will make several serious attempts before they reach their goals.
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Be kind to yourself if you do slip and haven’t achieved all your goals. Remind yourself of current research that says that change doesn’t happen overnight. Be patient.

Look at your goals and plans and think about why you have gone back to your old drinking patterns. Revise your goals and plans and try again.

Remember, small steps in the right direction take you closer toward your goal.

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Substances and Mental Health

For more information, see Fact sheet 9 Reducing alcohol and other drugs at http://www.beyondblue.org.au or call the beyondblue info line 1300 22 4636

Substances and Mental Health Dangers of illicit substance use

People who use illicit substances are more than twice as likely to have a serious mental illness as those who do not use illicit substances.

Though there are far fewer users of illicit substances in comparison to users of nicotine and alcohol, the mental health consequences of illicit substance use are a very serious problem.

Approximately 900 deaths and over 11,000 hospitalisations are associated with illicit substance use each year. But this is not a clear indication of the effects these substances have on mental health. It simply hasn’t been possible to establish a clear picture of the magnitude of these effects, because many people with a mental health problem or a mental disorder associated with illicit substance use remain undiagnosed and untreated. It is also often impossible to tell which problem came rst, the drug problem or the mental disorder. Many people do develop drug problems in an attempt to deal with their depression or anxiety.

What we do know is that the use of illicit substances can play
a signi cant role in causing and maintaining, anxiety, depression, paranoia, confusion, panic, psychosis, and other problems.The use of these substances can also:

−  conceal or obscure the symptoms or presence of a mental illness from those who could help you

−  worsen the symptoms of mental illness

−  inhibit recovery from mental illness

−  interfere with the effectiveness of prescribed medication

−  interact dangerously with some prescribed medications.

  

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Am I dependent?

Dependent has replaced ‘addicted’ in medical terminology. It is important to consider whether you are dependent as this can be more dif cult to address and have a great impact on your mental state.

Generally, you are dependent on a substance if you:

• continue to use the substance despite it causing problems
for you or others

• have tolerance to the substance or use it to relieve
withdrawal symptoms.
One of the most important aspects of dependence is that the substance use becomes a focal point of your day, often to the detriment of other activities or aspects of your life.
If established, once you have been dependent on a substance, it is very dif cult then to reduce your use to small amounts or just occasionally. Usually, your use creeps up again towards the old established patterns.You may need some help to overcome your dependence, if it is longstanding. In some cases, you may need to have treatment for withdrawal symptoms as you begin to deal with your drug use. It’s best to discuss this with your doctor.
Mental health problems and your decisions about substance use
Taking an illicit substance regularly or infrequently can interfere with your state of mind and mental health.When you have features of a mental illness and take an illicit substance, in order to recover, you may need to decide to stop (preferable) or
at least reduce your use.This is the case if, despite receiving treatment for your depression or anxiety, you are not making progress.

 

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Unravelling the connection between your substance use and depression

The way substance use and your mental health can interact can be very complex and change over time.The problem is that taking a substance will often, in some people, cause a short- lived state of mind which takes you away from the symptoms of depression or anxiety.The paradox is that there is generally a worsening of symptoms in the longer run.

For many people who take a substance regularly, their mental health improves gradually and markedly once they stop their intake. In these cases, treatments used for depression and anxiety disorders are unlikely to be very effective if substance use is ongoing or resumes. For some people, they only started to use when they became depressed or anxious, but the substance

use then developed a life of its own. In these instances, a plan
to deal with both is needed.This is possible.Treatments for depression and anxiety can help. But, ongoing substance intake can interfere with medical and psychological treatments for depression and anxiety.There are times when substance abuse can even distract from or obscure an underlying mental illness when you are seeking treatment, so it is necessary to inform the health professional of your substance intake and psychological symptoms if you are seeking help.

Some people assume that you cannot treat one problem until the other is resolved.This is not the case.You can address both at the same time, however, how much progress you make with either your substance problem or mental health problem depends on the relationship between them.

  

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256

Tackling both elements of your problem

Taking steps to address your depression and your illicit substance use yourself can be very effective.You can apply the strategies from the Alcohol chapter (page 225) to tackle your substance
use. If you are dependent, then you will need to decide on your goal with regards to your substance intake. Generally and overall, the best outcomes are achieved if you can aim to stop your use altogether.

Substance use is likely to make mental health problems worse. Until you can stop your substance use, you will need to make sure that you are safe when you use, particularly if you have been experiencing severe mental health problems. Some ways to do this include:

• do not use alone

• use smaller quantities

• do not mix it with medications

• take precautions if you intend to use and are already feeling
depressed or potentially suicidal

• tell someone you are using.
When you want to receive treatment for both problems from a health professional, this can be more challenging than if you had only one problem.This is because services such as mental health and drug and alcohol services are generally arranged to focus on one problem and not the other. General Practitioners are more used to seeing people with a combination of problems and are probably the best place to start for help.
Availability of illicit substances in rural and remote communities
There is a range of illicit substances that are available and being used in rural and remote communities. Some of the drugs mentioned in this section are generally common, such as cannabis and amphetamines. Other drugs like heroin and cocaine are less

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frequently marketed beyond the major urban centres.When and where particular drugs are available varies considerably. But it is reasonable to assume that even the most remote communities are affected by illicit substance use.

Illicit substances: known effects on mental health

In this section, only the potential effects of illicit substances on mental health are mentioned. It is important to note that the effects on physical health of some illicit drugs can be very serious – in some cases leading to death.

The effects of illicit drug use vary according to the potency of the substance, the amount taken, frequency of use, and the physical and health characteristics of the user.

The following descriptions are a basic guide only. More detailed information about illicit drugs is available on the internet and from the following Alcohol and Drug information services:

Druginfo Clearinghouse: 1300 85 85 84
[Note: Most 1300 and 1800 numbers cannot be accessed outside the states or territories in which they are based]

ACT (02) 6207 9977 QLD 1800 177 833 nSW 1800 422 599

(02) 9361 8000 nT 1800 131 350

SA 1300 131 340 or (08) 8363 8618

VIC 1800 888 236 TAS 1800 811 994 WA 1800 198 024

(08) 9442 5000

  

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258

Cannabis/Marijuana

Cannabis is the most widely-used illicit drug. It comes from
the hemp plant, and is usually smoked (sometimes mixed with tobacco) or mixed with food like ‘hash cookies’. Dependence (addiction) can occur with cannabis, even though there are no physical symptoms on withdrawal.Withdrawal symptoms can be prolonged, over several weeks, and include anxiety, an unpleasant, irritable, unhappy mood and agitation.

Known potential effects of cannabis/marijuana

These can arise during use, in intoxication and between episodes of use. Ongoing symptoms such as depression are more likely if there is regular weekly use.

• Confusion

• Anxiety – is one of the most common unwanted effects of
use

• Panic

• Impaired memory and learning

• Paranoia and suspiciousness

• Aggressiveness

• Depressive symptoms (such as loss of interest and motivation, withdrawal, lowered libido and lethargy)

• Psychosis – which may include one or more of the following:
− auditory hallucinations – hearing voices that aren’t there − visual hallucinations – seeing things that aren’t there
− delusions – believing things that aren’t true
− jumbled thoughts and strange behaviour.

• As well as causing these symptoms of mental disorders, cannabis use can actually bring on mental illnesses such as depression, anxiety disorders and schizophrenia in people who are vulnerable to developing them.The biggest risk of this is early in life during adolescence or early adulthood.

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Amphetamines

Amphetamine-related drugs are widely available and are often called speed. Illicit drugs from this group include amphetamines, methamphetamine and methylenedioxymethamphetamine – ecstasy.

The most commonly-abused amphetamine in Australia is meth- amphetamine which comes in different forms: tablets or capsules, crystals (often called ice) or a white, yellow or brown powder (more likely to be called speed) or paste (sometimes known as base).

Methods of use include swallowing, snif ng (the powder), injecting and (with the crystalline preparation) smoking. Most illegal methamphetamines are manufactured in makeshift laboratories and ‘cut’ (diluted) with different substances to boost pro ts.This means the person using the drug has no idea if the dose is strong or weak, or whether it contains other dangerous llers. Some methamphetamines are smuggled into Australia from overseas. Users can become dependent on amphetamines.When this occurs, they are almost certain to notice some or many of the symptoms of mental illnesses listed below.

Known potential effects of amphetamines

Acute intoxication generally leads to elevation of mood, insomnia and in some, agitation. It depends on whether you are a regular user or infrequent user and the dose taken. Symptoms of depression, insomnia and anxiety are often seen during the ‘crash’ phase after a period of use and are often mistaken for an episode of clinical depression.

It is more common for stimulant users to identify their mental health symptoms as problems and seek help for
them, rather than to seek help for their substance use. It is worth remembering that many of the mental health problems experienced by regular amphetamine users will resolve when they stop their stimulant use.

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Potential effects on mental health include:

• Depression, anxiety and related disorders

• Changeable mood

• Restlessness and agitation

• Insomnia

• Abnormal excitement and talkativeness

• Paranoia

• Aggressiveness

• Psychosis – which may include one or more of the following:
− auditoryhallucinations–hearingvoicesthataren’tthere

−  visual hallucinations – seeing things that aren’t there

−  delusions – believing things that aren’t true

−  jumbled thoughts and strange behaviour.

• Heavy, prolonged use causes brain damage to parts of the brain concerned with re ned movement and executive brain functioning such as making complex plans and organisational ability.

• In addition to these effects, use can act as a trigger to the onset of a mental illness such as depression, anxiety disorders or psychotic illnesses in people who are vulnerable.

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Ecstasy

Ecstasy is a synthetic drug which acts as both a stimulant and hallucinogen, having the effect of speeding up the workings of the central nervous system and altering the users’ perception of reality. It is commonly used at parties and nightclubs, and is most commonly available in the form of tablets.

Known potential effects of ecstasy

• Confusion

• Depression

• Anxiety

• Paranoia

• Insomnia

• Psychotic symptoms such as hallucinations (seeing things or
hearing voices) Cocaine
Cocaine refers to the drug in both a powder (cocaine) and crystal (crack) form that is derived from the coca plant. It is snorted as a powder, converted into a liquid for injecting, or in its crystal form, is smoked.This is a highly-addictive and dangerous drug. Users experience a short-lived high that is immediately followed by intense feelings of depression and a craving for more of the drug. People can develop dependence on cocaine.
Known potential effects of cocaine

• Depression

• Anxiety

• Anger and hostility

• Paranoia

• Insomnia

• Hallucinations (seeing things or hearing voices that aren’t
there)

• Ongoing mood disturbance

   

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262

opioids e.g. heroin

Heroin is an opioid derived from morphine or codeine, which are chemicals found in the milk of the opium poppy. It is available in the form of a powder which is white to brown in colour. It can be smoked, snorted/sniffed, but is usually injected. Street heroin

is often mixed with other dangerous substances.Although heroin is the most recognised drug of abuse from this class of drugs, people often substitute other opioids for heroin when it is not available.

Most other opioids that are abused are prescribed drugs
which are diverted from people receiving prescriptions into
the black market or obtained illegally.They include methadone and buprenorphine (both are legitimately prescribed for heroin substitution programs and for pain), as well as codeine, morphine, pethidine and other similar medications. Some people only abuse prescribed opioids and they can experience the same range of dif culties as people taking heroin. Dependence on opioids is a serious problem. It can cause very unpleasant physical withdrawal effects when the drug is stopped abruptly which may require medication to manage.

Known potential effects of opioids

• Depression

• Dulled responses

• Poor concentration

• Anxiety

• Panic episodes

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Solvents

Solvents are volatile substances with fumes that users deliberately inhale (often using a plastic bag). Some of the effects are similar to alcohol, except that they usually diminish more quickly than alcohol. Inhaling the fumes of solvents can be very dangerous to mental and physical health. Although these substances are not illicit for adults, because they are frequently used by adolescents and children, their sale to minors is prohibited in many communities.

Some of the products which may be sniffed include:

• cigarette lighter re lls (butane gas)

• aerosols (where it is the propellant, often butane, which is inhaled)

• solvent-based adhesives (some glues)

• petrol

• pressure pack spray paint.
Known potential effects of solvents

• Impaired mental activity

• Decreased self-control

• Disorientation/confusion

• Hallucinations (seeing things or hearing voices that aren’t there)

• Delusions (believing things that aren’t true)

• Brain damage, particularly impairment to the parts of the brain responsible for memory and executive brain functions such as controlling impulses.

  

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264

Confidential options for obtaining information, counselling, referral and treatment

 

For information about substances/drugs

  

Want help to cut down or stop your use?

   

Concerned about a friend of relative?

  

Want to contact a local drug and alcohol outreach service?

   

Need advice about or help with withdrawal?

  

need Urgent Help?

Feel unsafe, out of control, highly restless or agitated, suicidal, or like you could explode and do someone harm?

   

Find the safest way of getting to the Accident and Emergency Department of your nearest Hospital (like asking a relative, friend or neighbour to take you). TWhere there is an issue of danger or safety as a result of drug use, there is also the option of calling an Ambulance by dialling 000

Speak to your doctor

Speak to your doctor

Speak to your doctor

Call Druginfo Clearinghouse 1300 85 85 84 [Note: Most 1300 and 1800 numbers cannot be accessed

outside the states or territories in which they are based]

ACT (02) 6207 9977
QLD 1800 177 833
nSW 1800 422 599 or (02) 9361 8000 nT 1800 131 350
SA 1300 131 340 or (08) 8363 8618 VIC 1800 888 236
TAS 1800 811 994
WA 1800 198 024 or (08) 9442 5000

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For Help With:

Understanding the effects of withdrawal

Problems of addiction to prescribed drugs (like sedatives, tranquillisers or pain medication)

Understanding the effects of misusing prescribed medication – or illegally or inappropriately obtained prescription medication

Concerns about drug interactions (mixed illicit drugs, or prescription drugs with illicit drugs)

        

Call Druginfo Clearinghouse 1300 85 85 84 [Note: Most 1300 and 1800 numbers cannot be accessed

outside the states or territories in which they are based]

ACT (02) 6207 9977
QLD 1800 177 833
nSW 1800 422 599 or (02) 9361 8000 nT 1800 131 350
SA 1300 131 340 or (08) 8363 8618 VIC 1800 888 236
TAS 1800 811 994
WA 1800 198 024 or (08) 9442 5000

Speak to a doctor

Speak to a pharmacist

 

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266

Grief

267

Warning Signs of Complicated Grief

Tickþthe signs that are familiar
r Denial of feelings about the loss; no external signs of grieving –

as if nothing had happened.

r Being unable to talk fully about, acknowledge, or express the loss, or express feelings about it. Can’t seem to be able to cry.

r Unending, unchanging or prolonged distress, sadness, depression or guilt − still intensely preoccupied with the person who died

rActing out of character:
− with money, such as spending extravagantly − by being sexually promiscuous
− making major changes in lifestyle or activities

r Self-neglect: disinterest in personal appearance, eating properly or taking prescribed medication

rExcessive use of alcohol or sedatives

r Feeling agitated, restless, or manic

r Prolonged lethargy, fatigue; noticeable physical and mental slowing down

r Have become very absorbed in, and preoccupied with, helping and supporting others

rUsing work (working more than before and most of the time) or some other activity, as a way of keeping busy; ‘getting on with things’, in order not to have to feel the pain of grief

rUnnerving fear (or phobia) about illness or death
r Being careless, reckless, taking unnecessary risks (e.g. driving

fast or dangerously)

r Having thoughts about suicide, death, or self-harm

rFeeling strong guilt about things other than actions taken or not taken at the time of the death

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rHave been functioning very poorly for a prolonged period

rStrongly xated on self-worthlessness

rHearing voices or seeing strange things other than hearing or momentarily seeing the deceased person.

If some of these signs or symptoms are familiar –

.TAKE ACTIon.

Arrange to speak to a doctor. After medical assessment, you may be referred (or will need to request referral) to a grief therapist.

Having thoughts about suicide or self-harm are serious. If you are having these thoughts –

.TAKE URGEnT ACTIon.

Arrange to speak to a doctor OR

Phone a 24-HoUR MEnTAL HEALTH EMERGEnCY LInE national
Lifeline: 13 11 14
Suicide Call Back Service: 1300 659 467

State and Territory

ACT: Crisis Assessment and Treatment Team: 1800 629 354

nSW: Salvo Suicide Prevention & Crisis Line: Metro 02 9331 2000

Salvo Suicide Prevention & Crisis Line: Rural 1300 363 622

Suicide Prevention and Support: 1300 133 911
nT: Mental Health on Call Team:Top End (08) 8999 4988

Mental Health on Call Team: Central Australia (08) 8951 7777

QLD: Salvo Crisis Counselling Service: Metro 07 3831 9016 Salvo Crisis Counselling Service: Rural 1300 363 622

   

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SA: Mental Health Assessment and Crisis Intervention Service: 13 14 65

TAS: Mental Health Services Helpline: 1800 332 388 VIC: Mental Health Advice Line: 1300 280 737

SuicideLine: 1300 651 251

WA: Mental Health Emergency Response Line: Metro 1300 555 788

Rural Link: Rural 1800 552 002 Samaritans Crisis Line: 1800 198 313

nATIonAL HELP/InFoRMATIon LInES

beyondblue info line: 1300 22 4636
Lifeline: 13 11 14
MensLine Australia: 1300 78 9978
Kids Helpline: 1800 55 1800
Australian Psychological Society Referral Line: 1800 333 497 SANE Australia: 1800 18 7263

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About Grief

Grief is the reaction we have to most signi cant losses in our lives. Some of the losses that commonly give rise to a grief reaction include:

• ending a relationship
• loss of career or employment
• death of a pet
• loss of a signi cant role or position of status • loss of health
• loss of cherished plans, a goal or dream.

One of the most disturbing losses that all of us will be likely
to experience is bereavement: the death of a person who is signi cant to us. Since bereavement often gives rise to a major grief reaction, what we observe of bereavement grief can help us to make sense of the grief of most other losses. Bereavement grief will be the focus of this section.

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Bereavement Grief

The grief of bereavement is a reaction, psychologically and physically, to the changes thrust upon us because of a person’s death. We are forced to nd a different way of going about our lives, coping with the gaps, and a whole host of unforeseen changes and happenings.

How severely we experience grief, and for how long, depends on many factors such as: what the lost person meant to us – how signi cant the person was to our sense of well-being or security; how involved we were with the person; what role we played in caring for him/her (such as in the case of a long period of illness); how strongly we identi ed with the person’s experience or that of others around him/her. Our state of mind, health, emotional resilience, and what other things were happening in our lives at the time, are also factors.

Bereavement is not only a major loss in itself, but it often sets off a chain reaction of other losses (that may also have to be grieved and adapted to) such as:

• loss of income or nancial security/stability

• loss of routine, stability, and order promoted by (amongst other things) the demands of having to adopt new roles (perhaps once those of the deceased) and take on new tasks and responsibilities

• loss of a future together, or one in which the deceased would have played a signi cant role

• loss of home or accommodation arrangements

• loss of mutual friends

• loss of opportunities for social gatherings and interactions that were previously linked to the deceased person’s work or interests.

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Although its initial intensity usually diminishes with time, grief may be felt for an extended period, even up to several years. Sometimes, the pain of grief intensi es during the rst few months after the death, because not only are the reality and consequences of the loss ‘sinking in,’ but the support of others tends to fall away – often because people less affected have moved on or, if similarly affected, are preoccupied with their own pain and struggle.

Grief is a journey that demands a lot of patience, effort, energy, and a preparedness to experience much emotion. As well, it calls for the courage and daring to walk a new path, and to adapt to new challenges with hopefulness.

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Normal Grief

Normal grief encompasses a whole range of emotional and mental experiences, characterised by:

Shock – Feelings of numbness, unreality, emotional detachment, being in a dreamlike state, which may last for minutes, hours, or weeks.

Pain of grief – A very painful emotional/psychological anguish, with often considerable physical discomfort, including: shaking, wrenching of the gut, uncontrollable crying, chest pain, and weakness. This ‘whole of person’ anguish is what we term grief. Grief can be powerfully intense at rst, only subsiding with the passing of time – but often able to be reactivated by reminders of the deceased.

A sense of loss – This is often the trigger for grief: realising at an emotional level that the one who has been lost cannot be retrieved. This is the experience of losing not only the person who has died, but also all of the things associated with the relationship, such as companionship, shared activities and responsibilities, communication, affection, future plans.

Anger – A common emotion associated with being or feeling powerless, losing one’s sense of order, control; being unable to change or alter what has happened.Anger may be directed at others (because it often needs someone to blame) or at oneself.

Guilt – often mingled with regret and anger, may be felt for
not being the person who died – for surviving; or because of some sense of responsibility for the death, for the degree of the deceased person’s suffering, for not having been honest, available, loyal, caring enough – or perhaps insistent about that person’s safety or health. (“Why didn’t I make her stop smoking?”)

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Regrets – are common no matter how good a relationship was; regrets about things left undone or unsaid, or about missed opportunities – how things could have been.

Anxiety and fearfulness – are a response to life’s order, predictability, security, and one’s own sense of balance having been overturned. Being faced with such upheaval, and a keen sense of emotional vulnerability, can bring waves of acute anxiety and feelings of panic.

Intrusive images – These can occur particularly if the death happened in dramatic or traumatic circumstances, or where immense meaning was associated with the events of the death. Such images can be quite vivid and detailed, and may emerge most when one is alone, before going to sleep, or when one is mentally less active.

Mental disorganisation – In the early weeks of bereavement – and sometimes persisting for months – the experience of some mental disorganisation including poor concentration, confusion, forgetfulness, and being easily distracted, is common.

Feeling overwhelmed – The sometimes immense emotional and mental upheaval of loss and grief can be experienced as profoundly overwhelming – including for people who have
always prided themselves on their ability to cope with adversity. Compromised in their usual capacity for thinking things through and maintaining emotional balance, they may nevertheless have to deal with a whole range of practical tasks and demands.

Relief – When a spouse, partner, relative, or friend has suffered a prolonged illness, or much pain, dis gurement, or personality change, it is quite normal to feel relief when they die – because of their suffering (and one’s own feeling of being powerless to change the inevitable), or perhaps because of being fatigued by the great demands of devoted caring.

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Loneliness – It is common, even in the company of caring and supportive relatives and friends, to feel very alone in grief. After several months of bereavement, a person may feel loneliness most severely. Other people (perhaps less close to or involved with the deceased) have moved on; their lives appear to be back to normal. The blurring and preoccupying pain and turmoil

of grief begins to permit the realisation of aloneness in a new and stark way: the loss of companionship, sharing of intimacy, experiences, daily tasks and responsibilities. Particularly for the elderly, loneliness can be a profoundly diminishing and depressing experience.

Positive feelings – Grief does not prevent positive feelings and experiences altogether. Quite contrary to any idea of showing disrespect for the deceased, they may be a celebration of, and compliment to, the quality of a former relationship. That one can sometimes emerge out of grief and see the goodness of life, the future it holds, and experience some ordinary day-to-day things with joy and pleasure, is a sign of ‘healthy’ grief.

Adapted From: Stroebe,M. et al. Handbook of Bereavement:Theory, Research and Intervention (U.K, Cambridge University Press, 1993).

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Grief Avoidance

No one wants to experience the pain and upheaval of grief. Who wouldn’t want to avoid it? The problem is that it can only be avoided at our peril. It doesn’t go away if ignored – if anything, it becomes even more overwhelming for having been delayed.

IMPoRTAnT

People who are grieving will from time-to-time need to ‘take a break’ or be distracted from the pain and emotion of grief. They will also need to pay attention to the new tasks, challenges, role demands, and practicalities created by bereavement (which will tend to prompt, on occasions, a return to experiencing grief emotion). Part of healthy coping with grief is when a person moves between the pain and emotion of loss and the tasks, challenges, and practicalities

of ‘restoration’: attending to life changes, doing new things, forming a new identity and new relationships.

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It is when these patterns become rigid, xed, or are used excessively that they become a problem, because they supplant a normal process of grieving.

Seeking to avoid grief altogether is never helpful. Bereaved people commonly use one or more of a variety of grief avoidance patterns in a bid to escape dealing with grief. Some of these patterns are a quite legitimate, temporary means of survival and coping. People who use these patterns are usually unconscious or only partly conscious of doing so.

Continually avoiding grief means avoiding feelings, the capacity to enjoy life, living and loving; this results in moving away from oneself and others.

To deny, continually suppress, block, or deaden a grief experience can have serious consequences for:

• mental health

• physical health

• relationships

• personal safety

• future life.

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Grief Avoidance Patterns

Potential Consequences

Postponing

“I don’t want to deal with it now…. I’ve got too much else to do.”
This is ne as a temporary or occasional respite from grief.

When grieving is postponed for a prolonged period, it builds up inside and can become explosive.
Postponing grieving by
getting on with things is often reinforced by others who compliment the bereaved person for “doing very well.” Sensing this build-up as unsafe, the bereaved person has further reason to postpone experiencing feelings related to the loss.

Misdirecting grief emotions

By not acknowledging grief or not allowing the grieving process to occur properly, some people misdirect the emotional content of grief onto other issues or other people. Shifting the powerful emotions of grief away from their proper setting and source can cause confusion and real problems.

This can damage relationships, by exaggerating issues and problems. It can cause the person to become increasingly angry; to feel powerless, overwhelmed, or even under attack by others. Pressures of work and daily living

can become ashpoints for reaction and defensiveness.

Replacing

A quite common pattern, replacing describes when a person prematurely shifts the emotional focus that was

Grief does not go away by being ignored, or because some nurturing is experienced in a new relationship. It

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once part of their relationship with the deceased onto a
new relationship. This diverts attention away from the grief associated with the deceased; but only temporarily, and with often destructive consequences.

is a powerful force, and if ignored can be corrosive of the bereaved person’s mental state and emotional stability, as well as undermining the new relationship – often spelling hurt and misunderstanding for both people.

Minimising

The minimiser attempts to convince him/herself and others that he/she is coping really well and has not been overly affected by the loss. Avoiding pain at all costs, the minimiser deludes him/herself that ‘thinking through’ grief
is the same as the necessary experiencing grief. There is a tendency to rationalise away the vital felt component of grief.

Trying to convince him/herself that grief has been overcome (which is often applauded
by others as “coping really well”), the bereaved person becomes less able to engage with the emotion of grief, and sets him/herself up for being overwhelmed by it; which can contradict their former claims.

overworking

Again a very common avoidance pattern, overworking describes when a bereaved person over-invests in work as a way of leaving no time available to think or feel about the loss. Common advice by well-wishers is often,“Keep busy and occupy your mind.”

Unfortunately, compulsively overworking to avoid the pain of grief usually results in more pain, once grief can no longer be avoided or organised out of the daily work schedule.

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Retail therapy

This avoidance pattern provides only very short-term relief from the necessity of grieving. Nevertheless, some people throw themselves into a disastrously unrestrained pattern of shopping. Some may rationalise this behaviour as “being kind to myself for once” or “doing something for me.”

The consequence of this behaviour will, at best, be disappointment at its short- lived effect. At worst, it may create a whole new problem to add an unnecessary burden to grief: nancial debt and guilt associated with it.

overeating

Overeating is well known to be a behaviour exhibited
by emotionally deprived children: using something
that is available, in some sense to compensate for a person (usually a relinquishing or absent parent) who is unavailable and yearned for. In bereavement, overeating may be an unconscious attempt to ll the emptiness – to compensate for the void created by loss.

We also know that when people appear unable to acknowledge stress, hunger centres in the brain are stimulated.

Overeating is sometimes characterised by a compulsive craving for food, which a person may feel powerless to stop.

The unfortunate consequences of overeating are the physical and psychological problems that result from weight gain.

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Alcohol and drug use

Alcohol and other
drugs (including misused prescription drugs) are too often used to avoid the work of mourning loss.Well- meaning friends may suggest: “Here, take this, it will make you feel better.”

This is one of the most dangerous of avoidance patterns because, though seeming to improve mood and sleep, and though very effective in temporarily blocking out memories, it
is quite counter-productive. Using alcohol or drugs in this way may lead to signi cant problems of addiction and escalating dependence and abuse.

Alcohol, as an example, rather than having bene ts, may impair the quality of sleep, worsen mood and cause anxiety and agitation. Chemical abuse, as a means of avoiding the pain and process of grieving, may easily become a more generalised pattern of behaviour for years to come.

Moving away

Some people who are bereaved seek to avoid the process and work of mourning by staying on the move, travelling, or prematurely changing their place of residence. This may be prompted by a well-meaning friend advising:“What you need is to get away from it all.”

To move away from a familiar environment, social support, and the ‘prompts’ so useful to maintaining progress in the mourning process, may simply delay and intensify the inevitable accommodation of grief. Leaving what is familiar and supportive can also create secondary losses that further add to the upheaval of grief.

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Crusading

Crusading is becoming prematurely involved in or committed to a cause. It is probably quite true to say that we can,“help ourselves by helping others,” but not if this is a premature distraction from the necessary work of mourning. It is all too easy

to get passionately involved in voluntary work, like setting up a fundraising campaign for cancer research or a hospice, or throwing oneself into some other just cause, as a way of unknowingly trying to postpone the task of grieving.

Premature involvement in
a cause, albeit a very good one, can inhibit and delay the necessary work of mourning, and may cause ‘loss of face,’ guilt and regret at letting others down, when grief overwhelmingly demands attention.

Based on: Wolfelt, D. Grief Avoidance Response Patterns. (Centre for Loss and Life Transition, Colorado, US, 1993).

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Men and Women Grieve Differently

People will grieve in their own particular and individual way. It is important as well, to recognise that men and women tend to grieve differently. We are probably most familiar with how women grieve, because they tend to do so more publicly

than men. But if men are to be adequately and appropriately supported, we need to understand how their way of grieving often differs from that of women.

Women and grief

Women are usually very good at seeking out support for themselves and supporting each other. They tend to relieve their emotional pain through open expression of it, and talking about
it in the company of others. When women encounter dif culties with grieving, it is usually not because they don’t accommodate the emotional experience of grief, but because they pay too little attention to the tasks, challenges, and practicalities of restoration: attending to life changes, doing new things, forming a new identity and new relationships.

Men and grief

Contrary to the popular view that men do not cope as well with bereavement and grief as women, research suggests that only when men are deprived of social support do they fare more poorly than women. But what is important to note, in comparing men and women, is that they exhibit differences in their way of grieving, and not just by choice, but because of differences in biology (brain functions and structure, and hormonal systems) and in society-reinforced roles.

  

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How men tend to respond to grief

• Men are not as self-caring or help-seeking as women.

• Men pay less attention to emotional pain than women,
until those around them appear ‘safe’ and things appear ‘in order.’ This is because men often distance themselves from the emotional content of dif cult or ‘threatening’ situations in order to remain vigilant and protective towards others.

• Men tend to need more time and have to make more of a conscious effort to connect with grief emotions.

• Men often need privacy, aloneness, or a ‘safe’ ritual place (like a cemetery), before facing and experiencing emotional pain.

• Men are generally much less verbal than women, preferring to ‘mull things over’ and think things through.

• Men tend to exhibit more anger than women.This can pose a problem for men, because people tend to be sympathetic to the more subtle emotions that women exhibit, and unsympathetic to men whose dominant emotion is often anger. Unfortunately, what is not realised is that behind anger there are usually all the subtle emotions (like sadness, yearning, and helplessness) and suffering, just as others are experiencing, but in different order of presentation.

• Men often respond negatively to pressure to be more public in their grieving than they feel comfortable with.

• Men usually achieve through activities, action, small rituals (connected to their grief), and ‘mulling things over,’ what women do by talking and ‘crying out’ their grief.

• Men bene t much from the company of other men (or working alongside other men); not necessarily by any verbal exchange, but just by another man being ‘present’ who cares, but doesn’t intrude.

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How grieving men can best help themselves

• By showing courage in allowing themselves to experience the painful emotions of grief (rather than continuing to push them underground)

• By communicating clearly to others their need to be alone and to deal with their feelings in private

• By not shutting others out, but keeping communication open in their relationships

• By ‘tuning in’ to their bodies (Some feelings can be expressed as physical health problems.)

• By consciously using rituals and activity through which to express and work with their grief

• By slowing down, and making time for being re ective, and to connect with their grief (making time to grieve in order for there to be time to heal)

• By staying close to reliable friends and talking to them

• By taking time out in the natural environment (away from
work), to be open, vulnerable, and re ective

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Coping with Grief

The emotional pain and internal upheaval that many people experience following a death can feel almost unbearable. Thankfully, the pain does ease with time, and some sense of internal order can be felt returning. But grief is not just feelings, it is a complex process of reaction to loss, adjustment to the absence of the deceased (with the many challenges that may create), and an endeavour to make sense of what has happened, what it means, and what it implies about the future.

Grief mostly resolves, and life, though never being quite the same (because some things have changed forever), nds a new order and balance, permitting hope and promoting again the experience of pleasure and the possibility of human happiness.

If this were not so, how would past generations have survived the grief of war, holocaust, disasters, and disease?

Though there are many factors that determine the course of grief and how well an individual copes and adapts, as with physical healing, there are many simple strategies and measures that can help to heal the grief of bereavement.

• Getting some time to yourself each day is important
for re ection, and to allow the experience of emotions, perhaps put on hold during the day. To avoid being interrupted, you may need to turn off your mobile phone or go somewhere where you won’t be disturbed.

• Try writing down (in a private diary or exercise book) your thoughts of the day. Putting them where they can be seen may help you in making sense of them or just keeping them in proportion. Doing this (throughout the grieving process) can provide you with visual proof of your progress; this will be something you can come back to and be reassured by

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when you’re having a dif cult day or feel discouraged. It may also (in addition to thoughts) be helpful to make note of the different kinds of feelings you are experiencing and their intensity.

• Make an extra effort to spend time with other supportive people – especially when you least feel like it or are having a dif cult day. Interacting with other people can be very helpful in giving your mood a lift.

• Having a good cry can leave you feeling a whole lot better, and is an important step in the healing process. It may be necessary to nd a place where you can do this, where you are sure you won’t be seen or heard. It will be well worth the effort.

• Avoid making any major decisions, at least (if possible) for the rst year of bereavement.

• Try to take life one day at a time; don’t think too far ahead and, when dif cult problems come up that have to be dealt with, try using the Structured Problem-Solving method to help (see page 294).

• One of the most dif cult issues to think clearly about and to deal with when you are grieving is nances. It is in this circumstance that you can most justify and bene t from the assistance of a nancial advisor, accountant or rural counsellor. No one wants to make their business known to others, but some occasions, like bereavement, need to be an exception.

• Talk about the person who has died with other people – especially those who knew him/her.Though this may be quite uncomfortable at rst, it can increasingly diminish the pain of grief and the power of the whole situation to feel so wounding.

• Find someone you feel comfortable con ding in and who is a good listener. You may need to ask your doctor or your nearest Community Health Service to recommend someone who has specialist grief counselling training.

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Remember, even if your rst experience of speaking to someone like this doesn’t work out, don’t give up; try to nd someone else, because they may prove to be a vital lifeline. A grief counsellor will normally be trained to
help you cope with and make sense of the experience, emotional adjustments, and tasks of grieving. Some of these include:

−  the need to accept the reality of the loss

−  working through and allowing for the experience of
emotional pain

−  adjusting to the physical absence of the deceased

−   nding a new and enduring place for the deceased in your life; such as nding ways to remember the person so that he/she remains ‘present’ and continues to be valued, whilst still allowing for life to go on and progress.

• Write letters to the person you have lost, expressing your feelings and thoughts. Read them at the person’s graveside, keep them in a safe place, or maybe put them under a tree or bush planted in his/her memory.

• Create a memorial for the person who died: plant a tree, build something in the garden, compile a photo album, or create a mementos box with signi cant things in it.

• Commemorate the person on special days (on birthdays, Christmas, anniversaries or other signi cant occasions): light a candle, eat or drink something that the person liked, put their photograph out in pride of place.

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Taking Care of Yourself

• Try to get into a regular daily routine with set times for getting up, eating meals, and going to bed.

• Avoid trying to feel better or covering over your grief through alcohol, smoking, medication, or other drugs.

• Avoid too much coffee or tea, and other drinks that have caffeine in them (like cola), because they can make getting to sleep more dif cult and can worsen any tendency to be anxious.

• Get yourself relaxed well prior to bedtime to improve getting to sleep. See Restoring a Pattern of Normal Sleep, included on page 298.

• Do some outdoor activities (preferably not associated with work) like walking or gardening – to refresh you mentally.

• Try to achieve a balanced diet, including: breads, cereals, lean meat, sh, lots of vegetables, fruit, and some dairy products.

• Find ways of regularly relaxing. Use especially relaxing music, a relaxation tape, meditation, or some other proven method of relaxation (see Progressive Muscle Relaxation on page 189).

• Get regular daily exercise to help your mood and general sense of well-being. It doesn’t need to be strenuous. If you are concerned about physical health problems, or haven’t had a medical check-up lately, make an appointment to see a doctor.

• Give yourself permission to take a break from grief sometimes and do something enjoyable and pleasurable.

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Helping Someone Else Cope with Grief

Although we may feel awkward and blundering in our attempt
to support someone who is bereaved, so long as we are genuine, and are not using the situation to explore or grapple with
our own feelings or issues, then our efforts may prove really helpful for them. How well a person copes with grief depends signi cantly on the quality of support they receive from others.

The following suggestions are a basic guide for helping someone else to cope with grief.

Things to do

• Provide practical assistance. Often more than anything else, a bereaved person appreciates help with practical things such as work-related tasks and responsibilities (for those living on a farm, this may include mending a fence, getting a tractor in for repair, dealing with stock issues), childcare, bill paying, mowing a lawn, domestic chores or cooking. It may ring hollow to wish a person well if what they are most needful of is practical help.

• Don’t be afraid to visit and ask how they are, or to mention the deceased.

• Maintain contact, preferably in person, but also consider phoning, or sending a note or card. Support is often needed most once all the initial activity has subsided (after the funeral), and numbness gives way to raw painful emotion (sometimes persisting for several months).

• Talk about the person who has died using straight-forward language.

• Be aware of particular dates, anniversaries or times of the year that might be upsetting to the bereaved. Be available, call in and see them, telephone or send a card, to indicate your care and support.

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• Try your best to be a good listener: maintain concentration, be patient, and show by your body language, eye contact, and attentiveness, that you are interested.

• Accept their behaviour (unless it is unsafe) and their ways of dealing with the emotional pain of grief. Allow for emotion, expressions of blame, guilt, anger, and regret. Just let it be; just be present.

• If it seems appropriate and needed, offer the comments (not advice) that:
− Grief takes time (just like a physical wound that is painful before healing).
− Everyone grieves in their own way and in their own time. Things to be aware of:

• Respect the dignity and independence of the bereaved person. Put yourself in their shoes and imagine:“How would I feel in these circumstances – being spoken to like this?”

• Avoid giving advice, but if a matter of safety is involved, tell the person clearly what your concerns are.

• Before you offer support, decide what your commitment will be. It is most unhelpful to withdraw your support along the way because you’re not really committed or because you nd their emotions too uncomfortable.

• Avoid using clichés or platitudes; these most often come across as insincere and patronising.

• Don’t give false assurances or talk a lot because the situation feels awkward for you.

• Try not to talk about yourself, your own problems, or your own grief, unless you are asked and, even then, be sparing in what you say.

• Don’t say:“I know how you feel.” How you felt in similar circumstances was not exactly the same.

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• Avoid lecturing or imparting theory about grief. You could give the person something to read on grief if you think he/ she would be receptive to that.

• Don’t take over, and don’t ‘rescue.’ The last thing a person needs is to have to expend energy on avoiding unwanted help, or guring out how to tell a well-meaning rescuer to leave them be!

• Avoid suggesting any time frame about the duration of the person’s grief.

• Be conscious of not shifting the focus away from the bereaved person because what they are saying is tedious, uninteresting, or uncomfortable. Although the content of what the person says may be repetitious and full of familiar emotion, he/she may be helped considerably by being able to express it to someone they trust.

• Don’t trivialise their grief (“everybody experiences grief”). Don’t catastrophise their grief (“It’s a terrible thing…some people never get over it”).

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Structured Problem-Solving

For people who are bereaved, feeling stressed and overwhelmed by problems is common. Adopting a new way of tackling problems can be very helpful.

Structured problem-solving is a method designed to help you feel in control of your problems, and to enable you to deal more effectively with future problems.

The key elements of this method include:

• identifying and ‘pinning down’ the problems that have
contributed to you feeling overwhelmed

• thinking clearly and constructively about problems

• ‘taking stock’ of how you’ve coped in the past: your personal strengths, and the support and resources available to you

• providing a sound basis for important decision-making. With this method you can work on a single problem or follow
the process to tackle a number of problems.
Usually though – especially to begin with – it is best to deal with one problem that is speci c and potentially solvable.

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Structured Problem-Solving Involves 6 Steps

STEP 1

Write down the problem causing you worry or distress:

STEP 2

Think about your options for dealing with this problem (try to think broadly – including good and not so good options); write them down:

1.

2.

3.

4.

5.

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STEP 3

Write down the advantages and disadvantages of each option:

STEP 4

Identify the best option(s) to deal with the problem:

1.

2.

3.

4.

5.

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STEP 5

List the steps needed to carry out each option (bear in mind the resources needed and pitfalls to overcome):

1. a.

b.

c.

d.

2. a.

b.

c.

d.

3. a.

b.

c.

d.

4. a.

b.

c.

d.

5. a.

b.

c.

d.

STEP 6

Review your progress in carrying out your option(s):

What have I achieved?_______________________________

____________________________________________________

____________________________________________________

What still needs to be done? _________________________ ____________________________________________________ ____________________________________________________

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Restoring a Pattern of Normal Sleep

Sleep disturbance is common with bereavement. To restore
a pattern of normal sleep, it is important to practise sleep- promoting behaviours during the day, in the evening, at bedtime, and during the night.

Better Sleep Guidelines

During the day

• Organise your day. Regular times for eating meals, taking medicines, performing chores and other activities, help keep our inner clocks running smoothly.

• Regular exercise during the day (or early evening) can improve sleeping patterns. Avoid exercise late in the evening as this may make getting to sleep more dif cult.

• Set aside time for problem-solving and decision-making during the day to avoid worry or anxiety at night. (See Structured Problem-Solving included in this section.)

• Avoid napping during the day – go to bed and get up at regular times.
During the Evening

• Put the day to rest. If you still have things on your mind, write them down or put them in your diary to be dealt with tomorrow.

• Light exercise early in the evening may help sleep; exercise late in the evening may make getting to sleep more dif cult.

• Get into a routine of ‘winding down’ during the course of the evening, allowing at least half an hour of quiet activity, such as reading or listening to music, prior to bedtime.

 

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• Avoid drinking caffeinated drinks after about 4pm, and don’t drink more than 2 cups of caffeinated drinks each day (especially coffee, tea, cocoa, and cola).

• Avoid smoking for at least an hour (preferably an hour and a half) before going to bed.

• Don’t use alcohol to make you sleep, and keep your intake moderate (limit yourself to 2 standard drinks each day). Have 1 or 2 alcohol-free days each week.

• Make sure your bed and bedroom are comfortable – not too cold or warm.

• Ensure that your bedroom is dark and that the morning light does not lter in (except if you have a tendency
to oversleep, in which case it may be helpful to let the morning light into the room).

• Avoid a heavy meal close to bedtime. If you are hungry, a light snack might help you get to sleep.
At Bedtime

• Try to do the same things before you go to bed each night. Develop a calming bedtime routine, such as having a warm bath or shower, listening to relaxation music, or using a relaxation technique (see Progressive Muscle Relaxation on page 189). This way your body will learn to know that (with these activities) you are getting ready to go to sleep.

• Go to bed when you feel ‘sleepy tired’ and not before.

• Don’t read, watch TV, or have conversations or arguments in bed. Keep your bed and bedroom only for sleep (and sexual activity).

• Turn the light off when you get into bed.

• Relax and tell yourself that sleep will come when it is ready. Enjoy relaxing your mind and body, even if you don’t at rst fall asleep.

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During the night

• If you wake up too early in the night, don’t lie awake
for more than 30 minutes. Instead of just being awake
or worrying, get out of bed and do something that is distracting yet relaxing. Return to bed only when you feel sleepy again.

• Get up at the same time each morning. Don’t sleep late in the morning trying to make up for ‘lost sleep.’

• If you live in a place or area where there are sounds or noises that might wake you from sleep, have earplugs handy to block out the noise.

• Avoid sleeping pills – they do not provide a long-term solution to sleep problems.

300

GRIEF

Key Services and Resources

  

Key Services and Resources

When you call a crisis or information and referral number, you should expect a similar response from each type of service.

1. Information and Referral services

The phone will be answered by a trained operator who will:

• Listen to you

• Provide support by:

−  Offering advice and helping you nd information

−  Suggesting services that will be helpful including medical,
psychological and support services in your local area

−  Referring you to a crisis service if necessary (e.g. Lifeline)

−  Contacting a crisis service on your behalf if necessary.
2. Crisis services
The phone will be answered by a professional who will:

• Discuss your problems and provide information

• Provide an assessment and counselling (if needed)

• Provide support and counselling during a period of crisis

• Provide clear psychiatric information

• Provide referral to a service/person to assist you with ongoing care if needed including:

−  Specialist psychiatric service

−  Mental health team

−  General practitioner (GP)

−  Local support services.

KEY RESOURCES AND SERVICES

302

Helplines national

beyondblue info line: 1300 22 4636
Lifeline: 13 11 14
Kids Helpline: 1800 55 1800
MensLine Australia: 1300 78 99 78
SANE Australia: 1800 18 7263
Suicide Call Back Service: 1300 659 467
Carers Australia: 1800 242 636
Relationships Australia: 1300 364 277
Post and Antenatal Depression Association (PaNDa): 1300 726 306

Australian Capital Territory

Crisis Assessment and Treatment Team: 1800 629 354 Parentline: (02) 6287 3833

new South Wales

Salvo Suicide Prevention & Crisis Line: Metro 02 8736 3295 Salvo Suicide Prevention & Crisis Line: Rural 1300 363 622 Parentline: 1300 1300 52

northern Territory

Mental Health on Call Team:Top End (08) 8999 4988
Mental Health on Call Team: Central Australia (08) 8951 7777 Parentline: 1300 30 1300

Queensland

Salvo Crisis Counselling Service: Metro 07 3831 9016 Salvo Crisis Counselling Service: Rural 1300 363 622 Parentline: 1300 30 1300

South Australia

Mental Health Assessment and Crisis Intervention Service: 13 14 65
Parent Helpline: 1300 364 100

303

KEY RESOURCES AND SERVICES

 

Tasmania

Mental Health Services Helpline: 1800 332 388 Parenting Line: 1300 808 178

Victoria

Mental Health Advice Line: 1300 280 737 SuicideLine: 1300 651 251
Parentline: 13 22 89

Western Australia

Mental Health Emergency Response Line: Metro 1300 555 788 Rural Link: Rural 1800 552 002
Parenting Line: 1800 654 432

Information and referral

beyondblue info line 1300 22 4636 (national – local call cost)

The ‘Find a Doctor or other Mental Health Practitioner’ directory on the beyondblue website http://www.beyondblue.org.au is Australia’s rst list of health professionals who are specially trained to treat mental health problems. Use the interactive map to nd a health professional near you.

Medicare rebates on psychological services

All GPs can prepare a Mental Health Treatment Plan to manage the treatment of mental health conditions. GPs, psychiatrists
or paediatricians can refer people for up to 12 individual consultations (18 in exceptional circumstances) and 12 group sessions with a clinical psychologist, psychologist, social worker or occupational therapist in mental health or another GP quali ed to provide individual psychological therapy. A Medicare rebate can be claimed for these consultations.

Australian Psychological Society Referral Line: 1800 333 497 (national)

304

KEY RESOURCES AND SERVICES

beyondblue Information Found at http://www.beyondblue.org.au

These materials include Fact sheets, checklists, booklets and DVDs useful for people seeking information about depression, anxiety and related disorders and where help can be found.

beyondblue materials that can be used effectively in conjunction with this book are:

General depression information

• Understanding depression – information for adults (Fact sheet)

• Depression symptom checklist

• Depression (wallet card)

• Understanding depression and anxiety ( yer)

• What causes depression? (Fact sheet 3)

• Practical ways to help someone with depression
(information card)
Treatment

• A Guide to What Works for Depression (booklet, 64 pages)
– a comprehensive review of all known treatments for depression, including medical, psychological, complementary and lifestyle interventions

• A Guide to What Works for Anxiety Disorders (booklet, 64 pages)

• Types of help available (Fact sheet 4)

• Changing your thinking – Cognitive Behaviour Therapy (Fact
sheet 10)

• Antidepressantmedication–Adviceforadults(Factsheet11)

 

beyondblue has free information materials which can be ordered online or by calling the beyondblue info line 1300 22 4636

305

KEY RESOURCES AND SERVICES

 

• Help for depression, anxiety and related disorders under Medicare (Fact sheet 24)

• Benzodiazepines (tranquillisers and sleeping pills) (Fact sheet 44)

• Electroconvulsive Therapy (ECT) (Fact sheet 48)
Recovery

• Reducing stress (Fact sheet 6)

• Sleeping well (Fact sheet 7)

• Keeping active (Fact sheet 8)

• Reducing alcohol and other drugs (including smoking) (Fact
sheet 9)

• Recovery (Fact sheet 15)

• Healthy eating for people with depression, anxiety and
related disorders (Fact sheet 30)

• Keeping active for a healthy mind and body (information
card)
Family and friends

• beyondblue Guide for Carers – Supporting and caring for a person with depression, anxiety and/or a related disorder: Caring for others, caring for yourself (booklet)

• Information for parents (Youthbeyondblue Fact sheet 21)

• Taking Care of Yourself – andYour Family – after Retrenchment
or Financial Loss (booklet)

• How can you help someone with depression/anxiety? (Fact
sheet 1)

• Living with and caring for a person with depression/anxiety
(Fact sheet 2)

• Antidepressants for the treatment of depression in children
and young people (Fact sheet for parents and carers)
Related disorders

• Anxiety disorders (information card)

• Anxiety (wallet card)

• Anxiety disorders (Fact sheet 21)

• Post-Traumatic Stress Disorder (Fact sheet 31)

KEY RESOURCES AND SERVICES

306

• Generalised Anxiety Disorder (Fact sheet 35)

• Panic Disorder (Fact sheet 36)

• Obsessive Compulsive Disorder (Fact sheet 37)

• Speci c Phobias (Fact sheet 38)

• Social Phobia (Fact sheet 39)

• Bipolar disorder (Fact sheet 16)

• Reducing alcohol and other drugs (including smoking) (Fact
sheet 9)

• Eating disorders and depression (Fact sheet 42)

• Eating disorders and depression (information card)

• Problem gambling and depression (Fact sheet 45)
Perinatal depression

• Postnatal depression (Fact sheet 22)

• Emotional Health during Pregnancy and Early Parenthood
(standard booklet)

• Emotional Health during Pregnancy and Early Parenthood (booklet for parents of multiple birth children)

• Postnatal depression information and helpline numbers (information card for each state/territory)

• Edinburgh Postnatal Depression Scale – Checklist for pregnant women and new mothers
Depression and life stages or events

• Postnatal depression (Fact sheet 22)

• Grief, loss and depression (Fact sheet 28)

• Separated parents and tough times (Fact sheet 29)

• Men and Separation: Navigating the Future (booklet)

• Women and separation – Managing new horizons (booklet)

• Depression in older people (Fact sheet 17)

• Older people and depression (booklet)

• OBE … Our Stories A marvellous collection of personal
stoies from older Australians (booklet)

• Emotional responses after a disaster (information card)

• Looking after yourself after a disaster (booklet)

307

KEY RESOURCES AND SERVICES

 

Depression and chronic physical illness

• Chronic physical illness and depression (Fact sheet 23)

• Depression and coronary heart disease (Fact sheet 18)

• Depression and diabetes (Fact sheet 19)

• Depression after stroke (Fact sheet 20)

• Depression and dementia (Fact sheet 25)

• Depression and asthma (Fact sheet 26)

• Depression and arthritis (Fact sheet 27)

• Depression and Parkinson’s disease (Fact sheet 32)

• Depression and breast cancer (Fact sheet)

• Prostate cancer and the risk of depression/anxiety (Fact sheet 34)

• Maintaining your well-being: Information on depression and anxiety for men with prostate cancer and their partners (booklet)

• Anxiety disorders and depression in men with testicular cancer (Fact sheet 43)

• Depression and incontinence (Fact sheet 41)

• Brain tumours, depression and anxiety disorders (Fact
sheet 46)

• Depression and anxiety disorders in people with epilepsy
(Fact sheet 47)

• Serious injury and depression, anxiety and Post Traumatic
Stress Disorder (Fact sheet 49)
Depression and particular population groups

• Depression and anxiety in people who are gay, lesbian, bisexual, transgender or intersex (GLBTI) (Fact sheet 40)

• Depression in older people (Fact sheet 17)

• Depression in men (Fact sheet 12)

• Depression in women (Fact sheet 13)

• Depression in men (information card) – includes tips on
dealing with stress

• Depression in people who are deaf or hard of hearing (Fact
sheet 33)

• Do you have to tell your employer you have depression?

KEY RESOURCES AND SERVICES

308

(information sheet)

• Supporting the return to work of employees with
depression (information sheet)

• Older people and depression (booklet)
Youthbeyondblue – information for young people
See beyondblue’s website for young people: http://www.youthbeyondblue.com

• Depressioninyoungpeople(YouthbeyondblueFactsheet1)

• Dealing with anxiety disorders (Youthbeyondblue Fact
sheet 2)

• Getting help for depression or anxiety (Youthbeyondblue
Fact sheet 3)

• Treatments for depression and anxiety (Youthbeyondblue
Fact sheet 4)

• A Guide to What Works for Depression in Young People
(booklet, 52 pages)

• Antidepressants for the treatment of depression in children
and adolescents (Youthbeyondblue Fact sheet 5)

• Helpingafriendwithdepressionoranxiety(Youthbeyondblue
Fact sheet 6)

• Dealing with stress (Youthbeyondblue Fact sheet 7)

• Drinking, depression and anxiety (Youthbeyondblue Fact
sheet 8)

• Drug use and your mental health (Youthbeyondblue Fact
sheet 9)

• Cannabis and your mental health (Youthbeyondblue Fact
sheet 10)

• Recovering from depression or anxiety (Youthbeyondblue
Fact sheet 11)

• Staying healthy (Youthbeyondblue Fact sheet 12)

• Gettingthesleepyouneed(YouthbeyondblueFactsheet13)

• Suicide: knowing when to get help (Youthbeyondblue Fact
sheet 14)

• Managing self-harm (Youthbeyondblue Fact sheet 15)

• Dealing with loss and grief (Youthbeyondblue Fact sheet 16)

• Copingwithfamilybreak-up(YouthbeyondblueFactsheet17)

309

KEY RESOURCES AND SERVICES

 

• Understanding eating disorders (Youthbeyondblue Fact sheet 18)

• Makingthemostofstudying(YouthbeyondblueFactsheet19)

• Bullying (Youthbeyondblue Fact sheet 20)

• Depression and anxiety in young people who are gay,
lesbian, bisexual, transgender or intersex (GLBTI)
(Youthbeyondblue Fact sheet 22)

• Cyberbullying (Youthbeyondblue Fact sheet 23)

• Getting help for depression and anxiety – con dentiality
and costs (Youthbeyondblue Fact sheet 24)

• Concerned about a friend? (interactive ‘ ipper’ card for
young people)

• Information card for Indigenous young people
Languages other than English
For more information see http://www.beyondblue.org.au (Click Other languages)
A number of beyondblue’s depression and anxiety-related information materials have been translated into the following languages: Arabic, Assyrian, Bosnian, Cambodian/Khmer, Chinese simpli ed, Chinese traditional, Croatian, Dari, Farsi/ Persian, Greek, Indonesian, Italian, Japanese, Korean, Lao, Macedonian, Polish, Punjabi, Serbian, Somalian, Spanish,Tamil, Thai,Turkish,Vietnamese.
Merchandise

• beyondblue rubber wristband

• Youthbeyondblue rubber wristband

• beyondblue fridge magnet
DVDs

• Don’t beat about the Bush! – depression in rural areas

• Stories of Hope and Recovery – interviews with beyondblue’s
ambassadors

• Carers’ Stories of Hope and Recovery

• DepressionYarns:Tackling depression and anxiety in Aboriginal
and Torres Strait Islander communities

• Diabetes, depression and anxiety: Taking control

KEY RESOURCES AND SERVICES

 

310

• Tackling depression after stroke

• Building strong foundations:Tackling depression, anxiety and
related disorders in the construction industry
Braille/Audio formats
A number of beyondblue’s information materials are also available in Braille and audio formats. Call the beyondblue info line
1300 22 4636 for more details.
beyondblue Drought Campaign: Don’t beat about the bush! In response to the tough times country people have been experiencing as a result of drought, bush re and ood, beyondblue is working with a range of government and non-government agencies on the Don’t beat about the bush! Campaign which aims to increase awareness of depression, show people where they can get help and provide mental health support for communities. A range of resources is available to inform people where they can get help.

• Help for depression and anxiety info card − includes national helplines, websites and symptoms to look for

• Wallet-size info card with helpline numbers and signs and symptoms of depression

• beyondblue Fact sheet 12 − Depression in men

• Don’t beat about the bush! DVD − beyondblue presents a 20-minute segment on rural depression produced by the ABC Landline team. DVD includes beyondblue and Rural Doctors TV ads

• beyondblue Manual: How to organise a public forum on depression in your community

• For young people: Concerned about a friend interactive ipper card with depression info, help lines and websites

• The beyondblue Australian Rural Information Network (ARIN) Map at http://www.beyondblue.org.au shows the local support resources available to country people in drought-affected areas across Australia – including health professionals,Vinnies, Salvos, Centrelink,Australian Red Cross, nancial counselling services and drought support workers.

311

KEY RESOURCES AND SERVICES

 

national websites

Australian Drug Foundation
http://www.adf.org.au
Information on alcohol and drugs and on problems arising from their misuse

beyondblue: the national depression initiative

http://www.beyondblue.org.au
Information on depression, anxiety and related disorders, available treatments and where to get help

Black Dog Institute
http://www.blackdoginstitute.org.au
Information about bipolar disorder and depression

Bluepages
http://www.bluepages.anu.edu.au
Information about depression and treatments

Carers Australia
http://www.carersaustralia.com.au
Family carer support and counselling in each state and territory

Counselling Online
http://www.counsellingonline.org.au
Free, online professional drug and alcohol counselling

CRUfAD (Clinical Research Unit for Anxiety and Depression) http://www.crufad.org
Information and internet-based education and treatment programs for people with depression and anxiety

e-couch
http://www.ecouch.anu.edu.au
Online counselling service which provides information about emotional problems, including depression and anxiety disorders, and strategies to help prevent and manage problems

headspace – Australia’s National Youth Mental Health Foundation http://www.headspace.org.au

312

KEY RESOURCES AND SERVICES

        

Information, support and help for young people aged between 12 and 25

HealthInsite
http://www.healthinsite.gov.au
A wide range of up-to-date information on health topics such as diabetes, cancer, mental health and asthma

Kids Helpline
http://www.kidshelp.com.au
Web, email and telephone counselling for children and young people aged between 5 and 25

MensLine Australia
http://www.menslineaus.org.au
Support for men, especially those with family and relationship problems

Mental Illness Fellowship of Australia Inc http://www.mifellowshipaustralia.org.au
Information, support and advocacy for people with serious mental illnesses, their families and friends

MoodGym
http://www.moodgym.anu.edu.au
Free online Cognitive Behaviour Therapy program designed to prevent depression in young adults

Multicultural Mental Health Australia (MMHA) http://www.mmha.org.au
Information about the mental health and well-being of Australians from culturally and linguistically diverse backgrounds, including Fact sheets in languages other than English

PaNDa (Post and Antenatal Depression Association) http://www.panda.org.au
Information, telephone helpline and referral to anyone affected by post and antenatal depression, including partners and extended family

      

313

KEY RESOURCES AND SERVICES

 

Parentline
http://www.parentline.com.au
Parentline is a con dential telephone counselling service aimed at providing professional counselling and support for parents and others who care for children.

RANZCP consumer information http://www.ranzcp.org/resources/clinical-practice-guidelines.html
The Royal Australian and New Zealand College of Psychiatrists site contains psychiatric clinical guidelines and a series of Treatment Guides for consumers and carers available on the following topics: Anorexia Nervosa; Bipolar Disorder; Deliberate Self Harm; Depression; Panic Disorder and Agoraphobia; Schizophrenia.

ReachOut.com
http://www.reachout.com
Information to help young people through tough times

Relationships Australia http://www.relationships.com.au
Support and counselling for relationships

SANE Australia
http://www.sane.org
Information about mental illness symptoms, treatments, where to go for support and help for carers

Suicide Call Back Service
http://www.suicidecallbackservice.org.au
Online resources and telephone support and for those at risk of suicide, their carers and those bereaved by suicide

Youthbeyondblue
http://www.youthbeyondblue.com
beyondblue’s website for young people – information on depression, anxiety and how to help a friend

KEY RESOURCES AND SERVICES

     

314

Special Needs of Different Population Groups

Some population groups are more likely to experience depression and anxiety than the general population. Particular groups include new parents; people living with a chronic illness; Aboriginal and Torres Strait Islanders; young people and people who are gay, lesbian, bisexual, transgender or intersex.

Perinatal depression (PnD) and anxiety

Perinatal is the term used to refer to the time before and after the baby is born. During the pre- and postnatal period, women (and men) are at greater risk of developing depression and anxiety.

Left untreated, the impact of these conditions on the mother and her children may be profound. Children of depressed mothers may have a higher risk of cognitive, emotional and behavioural dif culties. Untreated, PND can also impact on family relationships and infant attachment. Some studies have indicated that the partners of women with PND may also be at greater risk of depression.

To order information materials, call the beyondblue info line 1300 22 4636 or visit the website http://www.beyondblue.org.au

• Postnatal depression (Fact sheet 22)

• Emotional Health during Pregnancy and Early Parenthood
(standard booklet)

• Emotional Health during Pregnancy and Early Parenthood (booklet for parents of multiple birth children)

• Postnatal depression information and helpline numbers (information card for each state/territory)

• Edinburgh Postnatal Depression Scale – Checklist for pregnant women and new mothers

  

315

KEY RESOURCES AND SERVICES

 

Chronic Illness and mental health

Research indicates that there are strong links between depression and chronic illness.

• Depression is common – one in ve women and one in eight men will experience depression at some time in their lives. For people who live with chronic physical illness, this gure is even higher. Research shows that 28 per cent of people with a chronic physical condition also have a mental disorder.

• Having a chronic physical illness puts a person at greater risk of developing depression.The symptoms of chronic physical illnesses, as well as some of the treatments, can result in major lifestyle changes which may cause severe disruptions to a person’s work, social life and create nancial dif culties.

• Depression also increases the likelihood of developing a chronic physical illness, particularly cardiovascular (heart) disease or stroke.

• For people with a chronic physical illness, depression makes recovery more dif cult. It can make it harder for people to nd the energy to eat healthily, exercise or take medication regularly.

• Having a chronic physical illness can also make it seem like
an effort to connect with family members and friends.This can make the person with the illness feel isolated and make it harder for him/her to recover from depression.
More information
Alzheimers Australia
1800 100 500 or http://www.alzheimers.org.au Information on dementia
Arthritis Australia
1800 111 101 or http://www.arthritisaustralia.com.au
Information and advice about arthritis and associated conditions

KEY RESOURCES AND SERVICES

  

316

Asthma Foundations of Australia
1800 645 130 or http://www.asthmaaustralia.org.au
Information, advice, education, counselling and support for people with asthma

Breast Cancer Network Australia (BCNA)
1800 500 258 or http://www.bcna.org.au
Information and resources for women with breast cancer

Cancer Council Australia

13 11 20 or http://www.cancer.org.au Information about cancer

Diabetes Australia
1300 136 588 or http://www.diabetesaustralia.com.au Information about diabetes

National Heart Foundation of Australia
1300 36 27 87 or http://www.heartfoundation.com.au Information on a range of heart-health topics

National Stroke Foundation
1800 787 653 or http://www.strokefoundation.com.au Information on stroke

Parkinson’s Australia
1800 644 189 or http://www.parkinsons.org.au
Information and support for people with Parkinson’s disease

Prostate Cancer Foundation of Australia 1800 22 00 99 or http://www.prostate.org.au Information on prostate cancer

       

317

KEY RESOURCES AND SERVICES

 

Aboriginal and Torres Strait Islander information

If you are an Aboriginal or Torres Strait Islander person reading this book or if you are concerned about an Aboriginal or Torres Strait Islander person, contact your local Aboriginal health service. The following can put you in touch with a range of support services including Bringing Them Home counsellors, information on Link Up services and other counselling options.

Of ce for Aboriginal and Torres Strait Islander Health (OATSIH) http://www.health.gov.au/oatsih
Comprehensive list of Aboriginal health services in each state and territory

National Aboriginal Community Controlled Health Organisation (NACCHO)
http://www.naccho.org.au
Links to Aboriginal Community Controlled Health Services and Aboriginal Medical Services in each state and territory

Australian Indigenous HealthInfoNet http://www.healthinfonet.ecu.edu.au
Information about Indigenous health, including detailed overviews of speci c health topics

Australian Indigenous Mental Health http://indigenous.ranzcp.org
Training modules to support mental health professionals throughout Australia in their work with Aboriginal and Torres Strait Islander people

Mental Health First Aid
http://www.mhfa.com.au
Provider of Aboriginal and Torres Strait Islander Mental Health First Aid Course

KEY RESOURCES AND SERVICES

    

318

Young people

Dif cult times can affect families in different ways. Young people and children can respond in a range of ways to either family changes or to outside pressures.The important thing is to be aware of any changes in a young person’s behaviour, thought patterns, feelings or physical symptoms.

Depression and anxiety are among the most common mental health problems experienced by young people. Unfortunately, the symptoms aren’t always recognised and young people therefore may not always get the help that’s needed. Sometimes the signs can be ignored, or passed over as “just part of growing up”.
Look for the signs that suggest someone isn’t travelling too well. (see beyondblue’s depression checklist on page 2)

More information for young people

Youthbeyondblue
http://www.youthbeyondblue.com or 1300 22 4636
beyondblue’s website for young people – information on depression, anxiety and how to help a friend, plus a range of Fact sheets on topics such as bullying, drinking and drug use, eating disorders, family break-up, studying and staying healthy.

Kids Helpline
http://www.kidshelp.com.au or 1800 55 1800
Free, con dential and anonymous, telephone and online counselling service for young people aged between 5 and 25.

headspace – Australia’s National Youth Mental Health Foundation http://www.headspace.org.au
Information support and help for young people aged 12 to 25.

ReachOut.com
http://www.reachout.com
This site provides young people with information and support on a range of issues including depression, dealing with exam stress and getting through tough times.

     

319

KEY RESOURCES AND SERVICES

  

Sources Used in the Preparation of this Book

KEY RESOURCES AND SERVICES

2007 national Drug Household Survey rst results, Canberra: Australian Institute of Health and Welfare, 2008

Anger – Managing Your Angry Feelings (Child and Youth Health, Online, 2003) http://www.cyh.com/HealthTopics/ HealthTopicDetails.aspx?p=240&np=298&id=2130

Alcohol and Your Health (Australian Alcohol Guidelines, National Health and Medical Research Council, 2009) http://www.nhmrc.gov.au/publications/synopses/ds10syn.htm

Alcohol: How Drugs Affect You (Australian Drug Foundation, 2009 http://www.adf.org.au/store/article.asp?ContentID=6748)

Are you Sleeping Well? (Adelaide,Vitalhealth, National Pharmacies,August 2001)

Ash eld, J. A Framework and Resources for Bereavement Counselling Practice (Adelaide, Calvary Hospital, 1998)

Ash eld, J. Gender, Masculinity and Manhood: Core Concepts for Understanding Men’s Issues (Australia, Ikon International Institute for Healing Arts and Sciences, 2003)

Ash eld, J. Bereavement Care Referral: observations for Bereavement Assessment – Adults (Adelaide, Palliative Care Unit, Royal Adelaide Hospital, 1994)

Australian Bureau of Statistics (2008) 2007 national Survey of Mental Health and Wellbeing: Summary of Results (4326.0), Canberra,ABS.

Australian Bureau of Statistics (2009) Causes of Death, Australia, Suicides 2007. (3303.0), Canberra, ABS.

Bagshaw, D. et al. Reshaping Responses to Domestic Violence (Adelaide, University of South Australia, 1999)

Bolton, R. People Skills (Australia, Simon Schuster, 1991) 320

    

Con ict Resolution (Child and Youth Health, Online, 2003) http://www.cyh.com/HealthTopics/HealthTopicDetailsKids. aspx?p=335&np=287&id=1521

Davis, J. A Manual of Mental Health Care in General Practice (Canberra, Commonwealth Department of Health and Aged Care, 2000)

Davis, M. et al. The Relaxation and Stress Reduction Workbook Fourth edition (U.S.A., New Harbinger Publications, 1995)

Facts about Amphetamines, Ecstasy (The Alcohol and Drug Information Clearinghouse, 2003)

Fighting Fair (Con ict Resolution Network, Online, 2003) http://www.crnhq.org/pages.php?pID=11

Grie ink (Online) http://www.grie ink.org.au/?page_id=4

Hassan, R. Suicide Explained:The Australian Experience (Melbourne, Melbourne University Press, 1995)

Insomnia Management (Adelaide, Department of Human Services, Environmental Health Branch, 2000)

Keks, N. & Burrows, G, eds. Mental Health: Practice Essentials (Sydney,Australasian Medical Publishing Company, 1998 http://www.mja.com.au/public/bookroom/1998/mentalhealth/ mentalhealth.html )

Lehrer, P. & Woolfolk, R. Principles and Practice of Stress Management (U.S.A., Guilford Press, 1993)

Management of Mental Disorders Third edition (Australia, World Health Organisation Collaborating Centre for Mental Health and Substance Abuse, 2000) Volumes 1 & 2

Marijuana and Youth Violence (The Alcohol and Drug Information Clearinghouse, 2003)

National Health and Medical Research Council Australian Guidelines to Reduce Health Risks from Drinking Alcohol Canberra: Commonwealth of Australia, 2009

     

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Prescription Drugs: Abuse and Addiction (The Alcohol and Drug Information Clearinghouse, 2003)

SAMHSA (Of ce of Applied Studies, U.S Department of Health and Human Services, 2003 http://www.samhsa.gov/)

Stroebe, M. et al. Handbook of Bereavement:Theory, Research and Intervention (U.K., Cambridge University Press, 1993)

Stroebe, M. & Schut, H. The Dual Process Model of Coping with Bereavement: Rationale and Description (The Netherlands, Utrecht University, 1999)

The Right Mix:Your Health and Alcohol (Canberra, Commonwealth Department of Veterans Affairs, 2003 http://www.therightmix.gov.au/)

Walter,T. A new Model of Grief: Bereavement and Biography Mortality, Number 1 (1996), pages 7-25

Williams, R. Anger Kills (Australia, ABC Radio National, Health Report Transcript, 7 April 1997)

Wolfelt, A. Grief Avoidance Response Patterns (U.S.A Pallicom, June 1993),Volume 12, Number 2

Worden, J. Grief Counselling and Grief Therapy (U.S.A Tavistock Publications, 1982)

KEY RESOURCES AND SERVICES

 

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