As part of the Australian Government’s recommended stepped care model of mental healthcare, ‘e-Mental Health’ services (low-intensity online mental health interventions and resources) are becoming a much more important part of our mental health system.
With 1 in 5 Australians experiencing mental health difficulties, low intensity interventions can provide an ideal option for individuals with mild-moderate mental health symptoms where other options (e.g. psychologist referral, medication) might not be suitable. However, e-Mental Health services need not be an either-or choice when compared with face-to-face treatment. In fact, e-Mental Health services can fill multiple roles in the space between an individual seeking help from their GP and accessing treatment with a Psychologist, from initial psychoeducation and increasing acceptability of face-to-face services for first-time help-seekers, to crisis support between appointments, to providing interim support and brief intervention for busy periods where they may be on a waitlist.
Below is a brief guide to the range of e-Mental Health services available (Table 1), as well as an outline of the various roles e-Mental Health can play, and which services are most appropriate.
All listed programs have been developed by credible sources, such as the Australian Government, universities, and national nongovernment organisations.
Table 1. e-Mental Health Service categoriesHere is an outline of some of the ways e-Mental Health can be used to help our clients:
Head to Health
Previously ‘mindhealthconnect’, this is the Australian Government’s portal to mental health information and e-Mental Health services. It enables consumers to search for information and receive advice about their mental health needs.
|Telephone and Webchat||Telephone and online chat services, most often free and used for crisis support, information-seeking, or brief counselling.||
|Psychoeducation Websites||Freely accessible websites providing mental health information, and often general tips and strategies for wellbeing.|
|Online programs||Online self-guided courses that are either transdiagnostic (i.e. targeting common core mental health symptoms), or address a specific problem (e.g. Social Anxiety, PTSD). Some programs offer limited guidance from a therapist via phone or email. The majority of programs are free, with a few being low-cost.|
|Apps||Easy and convenient to use (as they are mobile- or tablet-based). However, due to the number of apps available on the market and the relative ease in creating them (compared to the more comprehensive online programs), many do not have experimental validation. As such, it is important to thoroughly check the content and credentials of any app before referring to it.||
1. As crisis support:
- Telephone and webchat services are a great option for clients to contact if they need immediate support out of hours or between appointments with their healthcare professional.
- Apps such as the BeyondNow Suicide Safety Planning app can help clients and their healthcare professional create a strong, structured plan for dealing with ongoing crises and distress.
2. Psychoeducation for first-time or hesitant help-seekers:
- Head to Health, the government’s mental health information portal, is a great place to direct clients to in the first instance.
- Psychoeducation websites are fantastic tool for providing information about general stress and wellbeing, specific diagnoses (e.g. generalised anxiety, eating disorders), or specific problem areas (e.g. parenting, relationship issues, work stress) to first time help-seekers.
- Online programs (particularly the transdiagnostic programs that don’t focus on a specific diagnosis, such as myCompass) are a great option for help-seekers who are hesitant or uncertain about face-to-face mental health intervention.
3. Interim support:
- If clients are on a waitlist or aren’t able to access timely support due to situational circumstances, online programs and apps can provide a great option to help them start working on their wellbeing in the meantime (which also means they can hit the ground running when they are able to commence face-to-face intervention).
4. To complement face-to-face treatment:
- Online programs and apps can help build on the skills being taught in therapy, such as CBT strategies, mindfulness and positive psychology. Whilst using these resources as a complementary tool can involve a little extra work on the part of the clinician (i.e. to be able to get to know the programs available and find ones that complement their work), it can really help to strengthen and reinforce the work done in session.
As human beings, we are encoded to survive by avoiding things that are likely to cause us pain, which we have learnt in the past to induce pain or which is stressful or unpleasant: be it that giant spider sitting on the clothing line, that shoulder pain that has been ongoing for a while, or an article that you have promised to write for your upcoming practice newsletter.
In the initial phases, avoidance can work very well. By just using the part of the clothes line that the spider has not occupied, by not thinking about the article I need to write or by working around my sore shoulder, I can pretend that everything is ok and continue on my merry way. We work around it. The problem is that things very seldom remain the same. My resident clothesline spider decides to expand his territory and take up more and more of my clothesline, my shoulder pain worsens to a point that I cannot reach up beyond my shoulder and my practice manager starts sending me “reminder emails” that I cannot avoid anymore. Whilst some avoidance can be a very successful strategy to keep us safe from stressful situations, unpleasant experiences or threats, it can also become counter productive
So what have I learnt about avoidance?
1. Avoidance can be helpful when threats are real. If that spider on the clothesline turns out to really be that gastly dangerous “it’ll kill a grown man within an hour” species that Australia seems prone to having, avoiding it is probably a good idea. We can never totally avoid all the things that we want to avoid. It is seldom that avoidance makes things go away. The spider is still on the line, my shoulder still hurts and the looming newsletter article deadline is still there.
2. Avoidance feeds fear and is an all consuming voracious creature. The more we avoid the greater the problem often becomes. This is particularly so with anxiety. The more anxious I feel, the more I avoid. The more I avoid, the more anxiety I feel. As time goes by, our world becomes smaller and smaller and we feel more and more trapped.
3. Avoidance prevents us from learning that something different can happen or that what we were so fearful of is not as bad as we expected it to be. It prevents us from really experimenting and checking it out, to determine if something is really a threat or not.
What have I learnt to do about it?
1. Acknowledge the problem. We cannot do anything about a problem until we acknowledge it. For me, it was acknowledging that I had a problem in my shoulder (and in all likelihood had torn a ligament), that I was frightened of that spider and that the thought of having to sit down and write an article brought back traumatic memories of writing my thesis.
2. Start small. Be it writing notes on what you’d like to include in the article, finding out about physiotherapists or reading up about whether your resident spider is indeed as dangerous as you imagined it to be. Keep pushing yourself to be at the edge of your comfort zone. Don’t try to aim for the big wins. Small sustainable goals are more likely to get you there. Remember the tortoise and the hare.
3. Get support and help. Having someone to walk you through the journey can be invaluable. It helps give you perspective, keeps you accountable and gives you someone to whine to at the end of the day. This is particularly so if you have been avoiding a situation because of traumatic experiences. Until you stop avoiding, it will continue to intrude in your life and limit you. It might be uncomfortable but keep practicing and trying. Eventually it becomes the new normal.
To quote loosely from Vivian Greene, perhaps life is not about trying to avoid the storms but learning how to dance in the rain. Now excuse me whilst I get a broom to try to relocate my eight-legged friend for the fifth time before I head out for my physiotherapy appointment.
Dr Jasmine Pang describes the impact early adverse childhood experiences have on individual later-life health and well-being, with advice for general practitioners and health providers in how to provide trauma-informed care.
Primary health settings provide a unique environment for the provision of trauma informed care. Many trauma survivors do not seek mental health services but look for help in primary care settings. Neither patient nor providers may be aware of the link between their current physical complaints and the connection to past trauma. Yet research has clearly shown a wide-ranging impact of Adverse Childhood Experiences (ACE).
The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and the links to later-life health and well-being. ACEs investigated included emotional abuse, physical abuse, sexual abuse, household intimate partner violence, household substance abuse, household mental illness, parental separation or divorce and incarcerated household members.
Results of the study found that almost two thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs. The study also found a graded dose response relationship between ACEs and negative health and well being outcomes across the life course.
The study showed that as the number of ACEs increases so does the risk for the following-
- Fetal death
- Health-related quality of life
- Illicit drug use
- Ischemic heart disease
- Liver disease
- Poor work performance
- Financial stress
- Risk for intimate partner violence
- Multiple sexual partners
- Sexually transmitted diseases
- Suicide attempts
- Unintended pregnancies
- Early initiation of smoking
- Early initiation of sexual activity
- Adolescent pregnancy
- Risk for sexual violence
- Poor academic achievement
ACEs continue to have a lifelong impact from conception to death as it disrupts neurodevelopment. This results in social, emotional and cognitive impairment, which causes the adoption of high health risk behaviours leading to disease, disability and social problems.
Role of General Practitioners
Despite the increasing evidence of the lifelong health impact of ACEs, research shows that less than one-third of primary care doctors screen for ACEs on a regular basis . This was often due to a lack of knowledge of the prevalence of ACEs, discomfort with asking screening questions and perceived role. Yet, the primary care physician is uniquely positioned to play a critical role in the identification of ACEs and facilitating appropriate treatment. Interacting with adults, children and their families at regular intervals can allow patients and providers to develop a trusting relationship, which can facilitate the disclosure of ACEs. Contrary to popular belief, research has shown that screening for adversity is acceptable amongst patients. In an adult primary care setting, 79% of patients were comfortable being asked about ACEs and 86% felt comfortable being screened for ACEs. However, patients would only disclose if asked directly in a safe supportive manner. In a study at the Health Appraisal Clinic at Kaiser Permanente of San Diego, there was a 35% decrease in office visits and an 11% decrease in emergency room visits among participants compared to the prior year when they started screening for ACEs. Addressing childhood adversity in medical settings offers clinicians a more complete picture of important social determinants of health and has a great potential to improve health care utilization and encourage help seeking behavior.
What is trauma informed care?
A programme, organization or system that is trauma informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices and settings.
What can General Practitioners do?
- Learn more about the provision of trauma informed care and about trauma. Understand that “problem behaviours” may be manifestations or symptoms of trauma, or coping skills that served to protect them when surviving their trauma.
- Routinely ask patients about trauma history and trauma symptoms. This can be done using formal screening tools (E.g. Primary Care PTSD Screen, Brief Trauma Questionnaire) or by asking if patients had ever experienced one of the 10 ACEs identified in the ACEs study. Find out more about how to do so in a way that patients can feel supported to disclose.
- Discuss the impact of identified traumatic events if the patient screens positive. Not everybody who has experienced ACEs have ongoing difficulties. It is important to explore if current functioning has been impacted and the patient continues to experience distress from the traumatic experience
- Provide a referral if needed
- Follow up with the patient
 Weinreb, L., et al (2010) Primary Care Companion Journal of Clinical Psychiatry, Screening of trauma in adult primary care settings, 12(6)
 Goldstein, E., Athale, N., Sciolla, A. F., & Catz, S. L. (2017). Patient Preferences for Discussing Childhood Trauma in Primary Care. The Permanente Journal, 21.
 Felitti, V. J., & Anda, R. F. (2014). The lifelong effects of adverse childhood experiences. Chadwick’s child maltreatment: sexual abuse and psychological maltreatment, 2, 203-15.
This article was written by Dr Jasmine Pang at Benchmark Psychology. Jasmine has a particular interest in supporting children, adolescents, parents and adults who have experienced traumatic or difficult life circumstances and is passionate about ensuring high quality services be made available to them.
Something’s not quite right
James was like any other 9-year-old, but at the first mention of school his whole body would shrink and he would stare at the floor. Even though he had some good friends and wasn’t being bullied, he really didn’t like school. He didn’t have any ‘obvious’ issues, but he just couldn’t seem to keep up with the schoolwork and even started to call himself ‘the dumb kid’.
Chloe needed constant help to do her homework and was embarrassed to read in front of others. She was losing her confidence and every day became a battle to make it through the afternoon. Her parents were worried because they could see that if they didn’t do something she would be left behind, and their cheerful little girl would slowly withdraw away.
Parents are the experts on their children. They know their children better than anyone else, and they know when things aren't quite right.
Ryan has always seemed a little different from his brother. He didn’t play the same games and would spend hours alone, lost in “Ryan’s World”. He seemed to be a bright kid, but he never quite got it when it came to friends. One moment he would be smiling up at his parents and the next he would be on the ground. His parents were lost for how to help him.
The myth of watch and wait
These stories are ones we hear every day. Unfortunately, parents concerned about their child’s development are all too often told to ‘watch and wait’. They’re told that they are just ‘anxious’ parents and that their child’s problems are ‘just a phase’. These messages are not only invalidating for parents – they leave children behind and leave families and educators lost.
The path to helping children develop begins with understanding.
Parents are the experts on their children. They are number one. They know their children better than anyone else, and they know when things aren't quite right. Trusting this intuition as a parent and getting support as soon as possible, can help children reach their potential and be the best they can be before a small problem becomes a big one.
Finding a path for your child
Sometimes parents feel like they’ve tried everything to help their child and nothing seems to make much difference. They feel like they are sailing in the dark – not knowing which direction to turn. The real issue is that often we don’t have a clear understanding of the child’s thinking style or view of the world.
The path to helping children who are experiencing challenges in their social, emotional, behavioural, or academic development begins with understanding. A developmental assessment can provide this key and open up the pathway to change.Assessments for children can include a range of developmental areas. For example, cognitive assessments help parents to understand their child’s way of looking at the world.
Assessments for children can include a range of developmental areas. For example, cognitive assessments help parents to understand their child’s way of looking at the world, and can detect if a child is struggling to keep up, if they need more help, or if they have difficulty with a particular area of learning (such as problems with reading or paying attention). Assessments can also target specific developmental challenges, such as Autism Spectrum Disorders or Asperger’s Syndrome, Attention Deficit Hyperactivity Disorder, and clinical anxiety.
At Benchmark Psychology, we have a team of clinicians experienced in a range of developmental assessments for children and young people. Assessments are conducted directly by registered a clinical psychologist or clinical neuropsychologist with experience in assessments and postgraduate university qualifications.
We only use the gold-standard measures for assessment, such as the Weschler Intelligence Scale for Children (WISC), Weschler Individual Attainment Scale (WIAT), and Autism Diagnostic Observation Schedule (ADOS-2).
Every family is engaged in their child’s assessment process from start to finish. Parents receive a written report, outlining the assessment steps, the findings, and detailed recommendations to help parents decide where to from here. Parents also attend a feedback session with the clinician to go through the report together, discuss the results, and ask any questions.
Benchmark Psychology also offer families full assessment packages at a low cost (compared to other psychological practices in South-East Queensland).
To find out more or book an assessment today, call (07) 3349 5511 or visit benchmarkpsychology.com.au/services/cognitive-assessment/ for information about cognitive assessments or
benchmarkpsychology.com.au/autism-spectrum-disorders-assessment/ for autism spectrum disorders assessment.
This post was written for us by Dr Grace Sweeney and Dr Richard Wellauer from Benchmark Psychology.
Pokemon GO is a mobile game that gets people walking around with their phones in the real world to collect virtual animals, items, and experience points. The app uses your phone’s GPS to work out where you and then allows you to collect different rewards in the game.
Already people are reporting that it’s helped them get out and about and as a consequence they feel more positive and are overcoming mental health issues such as depression. (Check out this article from the ABC for details.)
Although there’s not yet any published scientific evidence that playing Pokemon GO will improve your mental health, the rationale that Pokemon GO will improve mental health disorders like depression is pretty strong. However, there are also risks, and it’s possible that playing a game like this could also worsen some mental health symptoms.
Depression symptoms include low mood and a reduced level of activity. There is strong research evidence that exercise alone can improve depression symptoms, particularly for mild to moderate depression. Another key intervention is called ‘behavioural activation’ or ‘pleasant event scheduling’, which involves helping people to engage more in activities that they used to find enjoyable. Pokemon GO encourages people to get our more and increase their activity levels, so it’s likely that it would help with symptoms of depression.
Fear of the outdoors (agoraphobia)
Some people feel very anxious being outside or leaving the house, and if these issues significantly interfere with their daily life, they might be struggling with agoraphobia (fear of being outdoors). Cognitive behavioural therapy treatment involves gradually encouraging people to challenge themselves so they become desensitized to the feared situation. Pokemon GO could enhance motivation for people to overcome this fear, so it’s likely to help.
People with social phobia have an overwhelming fear that they’ll make a social faux pas or won’t know what to do or say in a conversation and so avoid social interactions and isolate themselves from others. Pokemon GO could help someone with social phobia to get out more and it also gives people something to talk about with other gamers, but a game like this can encourage people to avoid interacting in social situations and instead to get out their phones. Although the game has social aspects, it doesn’t really encourage people to use or improve their social skills and may not help people feel more confident in real life social situations.
Obsessive compulsive disorder (OCD)
People with obsessive compulsive disorder (OCD) have an overwhelming preoccupation with things being ordered and clean (contamination) or difficulty getting rid of possessions (hoarding). Pokemon GO encourages people to collect and collect and collect so that they can be the best and is likely to involve the same neural reward circuits in the brain that reward people for following their OCD impulses. Pokemon GO could encourage hoarding-type symptoms of OCD and also encourages people to spend more and more time on their phones to the exclusion of other activities.
People with gambling issues are so focused on the next reward or payoff that they neglect their other responsibilities or values. Pokemon GO encourages people to spend more time chasing after rewards and points and also allows you to spend real money to improve your status. If you’ve got a gambling problem Pokemon GO might be healthier than blowing thousands of dollars on the pokies but isn’t likely to cure your addiction.
Games like Pokemon GO can really help to improve people’s motivation to get out and about but they have a real potential to become addictive and lead to people neglecting other important areas of life. When used carefully they are likely to improve mental health for a substantial number of people, however, you need to be aware of potential negatives. There’s no blanket rule about when things like Pokemon GO should and shouldn’t be used but if people monitor both their game use and their mental health symptoms they can make a decision for themselves about whether or not a strategy like this is helpful or harmful for their situation.
The MY NAP Study
“Is your child on medication for a diagnosis of ADHD and having trouble sleeping?”
What is the MY NAP study about?
An international research team is undertaking a study to look at the effectiveness of Melatonin in helping children who have a diagnosis of ADHD, are currently treated with stimulant medication, and are experiencing sleep difficulties, particularly in getting to sleep.
This study is designed in a way that it can help provide information for individuals, and also group information. This information could be useful in determining if melatonin has a significant effect on sleep for your child.
Results from this study can be given to your doctor to help in treatment planning for your child.
This study is funded by the National Health and Medical Research Council (NHMRC).
Hyperactivity Disorder (ADHD)
ADHD is a complex disorder involving difficulties with hyperactivity, concentration and attention.
Children with ADHD often have difficulty sleeping with problems trying to settle down in the evening. This can be complicated by the medications used to treat ADHD (such as with stimulants like Ritalin, Dexamphetamine).
What is Melatonin?
Melatonin is a natural hormone that is produced by a part of the brain, called the pineal gland. It is often described as the hormone of sleep and it helps to regulate other hormones and maintain the body’s circadian rhythm. The body produces melatonin each night as it gets dark to promote sleep and “re-set” the body clock. In some health conditions, insufficient melatonin is produced, and melatonin supplements can help.
Melatonin has been used in children to help with their sleep from time to time, however the scientific research has not decided whether there is a true effect seen in children with ADHD.
One of the best ways is to see whether your child sleeps better with melatonin, or a placebo (inactive medication).
Who is eligible to
take part in this study?
- Children between the ages of 6 – 17 years;
- Who have a diagnosis of ADHD;
- Who are treated for their ADHD with Stimulants such as Ritalin,
- Who have trouble sleeping, i.e. take at least 45 mins to get to sleep at least three nights a week.
- Children who are already on Melatonin can participate in the study, but they will have to stop their melatonin use at the start of the first phase, as described below.
- Children with some other conditions that also affect sleep, eg. Autism, brain injury, seizure disorder or sleep apnea, may be unsuitable for the study.
What would be involved?
If you are interested in taking part in the study, please contact Dr. Jane Nikles via email: firstname.lastname@example.org or telephone (mobile): 0408 599 033 for further information and to confirm your child’s eligibility.
A referral from your doctor – your G.P or Paediatrician - is required for the study. If you are interested in participating, you will be asked to make an appointment with your doctor, and the study team will contact them to ensure they are fully informed about the study.
In the first phase, you would be asked to initially complete some questionnaires and be given information about healthy sleeping habits. Your child’s sleeping activity would be monitored for two weeks.
At the end of the two weeks, your child would be given the medication (either melatonin or a placebo) for 1 week blocks, for six weeks. All participating children will receive both melatonin and the placebo. During the six weeks, you would be asked to keep a sleep diary and complete more questionnaires. Your child will wear an activity watch to help us measure their sleep activity.
A report will be generated and sent to your referring doctor detailing your child’s individual responsiveness to melatonin. This can be used to guide ongoing treatment decisions.
There will be follow-up contacts three and twelve months after this.
Who are we?
The research team is part of an international group of researchers from Lady Cilento Children’s Hospital, Brisbane; The University of Queensland, Brisbane; and The University of Alberta, Canada. It is led by Dr Jane Nikles (UQ), Prof Geoff Mitchell (UQ), A/Prof Honey Heussler (Lady Cilento Children’s Hospital) and Dr Hugh Senior (UQ).
The project has been granted the following ethics approvals:
UQ HREC – 2012000999
For further information,
Dr. Jane Nikles
Mob: 0408 599 033
Prof Geoff Mitchell
A/Prof Honey Heussler
This is an interesting question that philosophers, psychologists, and psychiatrists have struggled with for years.