Welcome to Edition 224 of Institute Inbrief! In this edition’s featured article, we provide you with a sad, yet necessary (for the purpose of bringing awareness to the issue) brief overview of postnatal depression; including its outset, prevalence, consequences and risk factors.
Also in this edition:
- Latest news and updates
- Articles and CPD information
- Wellness tips
- Therapist Q&A
- Social media review
Enjoy your reading!
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Beyond Blue launch online program to help teachers
Australia's teachers are turning to the internet to help combat the increasing number of teenagers struggling to overcome mental health issues.
More than half of the 600 teachers and principals involved in an independent survey said it was difficult to find training tools to help staff tackle mental health concerns among students.
BeyondBlue board director and former Prime Minister Julia Gillard joined chairman and former Victorian premier Jeff Kennett at Unley High School in Adelaide to launch a program designed to deliver such resources online.
The program, called MindMatters, will be made available to 1,500 schools over the next three years.
Editor’s note: In 2011, AIPC developed and released a 217-page Anti-Bulling program for Australian primary and secondary school teachers. The program is entirely free and can be downloaded via the following AIPC webpage: https://www.aipc.net.au/bullyed.php.
Postnatal Depression: Onset, Prevalence and Consequences
Beverley had just become a mother. She was married, but the relationship was not satisfying or close. Beverley had not wanted to become pregnant, but she had carried the pregnancy to term and given birth. Severely depressed throughout pregnancy, Beverley’s contracted sense of emptiness and hopelessness now accelerated. She had recurring thoughts of suicide. And the child would simply not stop screaming!
One evening at bath time, Beverley gently pushed her reclining son’s shoulders down further into the water, causing his face to go under the surface. She kept her hands there until the infant’s movement stopped. The courts later acquitted Beverley for murder on the grounds that severe (postnatal) depression had constituted a mental illness causing her to act irrationally. It didn’t save her son, however; he was a victim of filicide, defined as the killing of a child by its parent (Friedman & Resnick, 2007).
There were 22 filicide cases recorded in Australia between July 2008 and June 2010, or 11 per year on average. Seven involved the death of a child less than one year of age (Chan & Payne, 2013). The United States has a rate of 500 cases per year (Orenstein, D., 2014), with rates of child homicide at 8/100,000 for infants – more than triple the rate for pre-school or school-age children – and these statistics are said to be an underestimate (Finkelhor, 1997). Mothers account for 37 percent of filicide deaths (Mouzos & Rushforth, 2003). An international review of psychiatric literature found that filicidal mothers often experience depression, psychosis, suicidal thoughts, and other prior mental health problems (Resnick, 1969, in Bartels & Easteal, 2013).
Postnatal depression, or PND, figures largely in these sad statistics; it has been estimated that at least one in five mothers of full-term infants suffers from it (Priest et al, 2005, in Statewide Obstetrics Support Unit, 2007), with one to four women per thousand giving birth suffering from post-partum psychosis, resulting in an inability to distinguish right from wrong (Schwartz & Isser, 2007). Filicide is the extreme tragic result of PND disorder.
In this article, we provide you with a brief overview of postnatal depression; including its outset, prevalence, consequences and risk factors.
Onset and prevalence of PND
Giving birth may be experienced by a woman as both joyful and stressful at the same time. In fact, most women experience a range of emotions, including the “baby blues”, a condition striking soon after delivery, peaking around Day 4, and disappearing by Day 10. The baby blues should not be confused with PND, also called “postpartum depression”, or PPD (The Carlat Psychiatry Report, 2013). This latter condition, experienced by about 13 percent of women giving birth, consists of more serious and persistent symptoms that meet the criteria for what the DSM-5 calls “persistent depressive disorder” (identified as a “major depressive episode” in the DSM-IV) with peri-partum (either antenatal or post-partum) onset (Stone, 2013). PND is said to have an onset up to four weeks after childbirth, but many experts use three months as a more realistic time frame (The Carlat Psychiatry Report, 2013).
PND is serious: The consequences
It is grave enough for a woman that she may experience being “down” after childbirth, as such women are more likely to become depressed during future pregnancies (Cooper & Murray, 1995). But the problems do not stop there. Post-natally depressed women also have increased difficulty developing a secure and healthy attachment with their children (Murray et al, 1999). Beyond that, PND has an immediate and lasting impact on the social, emotional, and cognitive growth of children (not only the newborn, but also other children in the family) (Carter, Grigoriadis, Ravitz, & Ross, 2010). Finally, partners of women with PND have been shown to have higher levels of anxiety and depression (Roberts et al, 2006) and greater distress in their relationships with their children and partners than men partnering with non-depressed women (Davey, Dziurawiec & Brien-Malone, 2006). Thus the serious condition of PND affects not just the woman, but the entire family system.
Looking in more detail, we can note that antenatal depression has been associated with higher norepinephrine levels in infants; infants born to mothers who were depressed both before and after childbirth had these changes and also elevated cortisol levels and lower dopamine levels (Diego et al, 2004). Anxiety is also disruptive during the post-partum phase, with identified anxiety equalling known obstetric risk factors in predicting birth complications like premature delivery and low birth weight (Wadhwa et al, 1993). The mother’s depression is also linked to later problems with infant temperament, inappropriate reactions to new stimuli, delayed motor development, and childhood problems such as anxiety, reduced attention span, and behavioural problems (Statewide Obstetrics Support Unit, 2007).
Medical experts contend that antenatal maternal stress triggers a response in the hypothalamic-pituitary-adrenal (HPA) axis to release cortisol, which increases the cortico-tropin-releasing hormone (CRH) in the placenta. Elevated levels of it there are associated with premature birth and restricted growth of the foetus; exposure to stress hormones in the uterus may program the foetus to be more reactive to stressors over the individual’s life. Moreover, maternal stress at the peripartum stage – such as when the mother is under stress, suffering from malnutrition or infections, and/or consumes alcohol or tobacco – may raise glucocorticoids, which interfere with the effects of growth hormone.
Sadly, even though babies with low birth weight catch up by one year of age, there may be permanent changes to the genes which regulate glucose and fat metabolism (thus triggering foetal programming of metabolic syndrome). When a child suffers the early difficulties of a mother with PND, there are also changes in the hippocampus and prefrontal cortex which will predispose the child to depression, anxiety, posttraumatic stress disorder, and cognitive/attentional deficits (Matthews & Meaney, 2005).
With so many vulnerabilities generated by perinatal depression, we would hope that the post-natal environment – meaning the quality of family life and nurturing – would be able to moderate the effects of such prenatally-determined diatheses. But we would be disappointed again. The tentacles of PND are seen to stretch to undesirable parenting practices and poor attachment, as depressed mothers fail to care properly for their infants.
Thus the whole range of cognitive, physiological, and emotional problems generated by PND fails to be mitigated. If we were hoping that the father would be able to compensate for the mother’s anxiety or depression, our final hope would probably be dashed. That is because, while the father might be able to develop a secure attachment with the child, it is more likely that, as stated earlier, fathers partnering with depressed mothers will tend to be more anxious and depressed themselves, thus spawning independent negative effects in the children, such as behavioural and emotional problems (Ramchandani et al, 2005).
What brings on PND: The risk factors
The aetiology of PND is considered to be comprised of multiple factors (Ross, 2004), at psychological, social and biological levels.
- Antenatal anxiety, depression or mood swings
- Previous history of anxiety, depression, or mood swings, especially if occurred perinatally
- Family history of anxiety, depression or alcohol abuse, especially in first degree relatives
- Severe baby blues
- Personal characteristics like guilt-prone, perfectionistic, feeling unable to achieve, low self-esteem
- Edinburgh Postnatal Depression Scale score > 12
- Lack of emotional and practical support from partner and/or others
- Domestic violence, history of trauma or abuse (including childhood sexual assault)
- Many stressful life events recently
- Low socioeconomic status, unemployment
- Unplanned or unwanted pregnancy
- Expecting first child or has many children already
- Child care stress
Biological / medical:
- Ceased psychotropic medications recently
- Medical history of serious pregnancy or birth complications, neonatal loss, poor physical health, chronic pain or disability (Statewide Obstetrics Support Unit, 2007)
Treatment of PND: A rationale for Interpersonal Therapy (IPT)
We can note how prevalent relationship risk factors are. Highlighting the social factors above, research has confirmed the more specifically stated social risk factors of marital conflict, lack of spousal support, having no partner, and reduced social support (Dennis & Ross, 2006; Beck, 1996; Beck, 2001). Some researchers have hypothesised that supportive relationships may serve as protective factors, buffering against depression (Mauthner, 1995).
The consistent finding of the converse truth – namely that relational factors also play a role in the development, maintenance, and recurrence of PND – means that we have a compelling rationale for a therapy which is interpersonally based. Research since the turn of the millennium, in fact, has had positive results focusing on the marital relationship as an effective place for Interpersonal Therapy interventions (Schulz, Cowan, & Cowan, 2006; Misri, Kostaras, Fox, & Kostaras, 2000). It is not surprising that IPT has been showing effectiveness with this population due to the disruptions to key relationships and social supports associated with PND (learn more about IPT here). The onset of depression when adjusting to motherhood makes IPT interventions working in the focal area of role transitions particularly applicable (Mulcahy et al, 2009).
The other factor guiding treatment choice for women with PND is that many do not wish to expose their breastfeeding infant to antidepressants. Thus, a non-pharmacological treatment such as psychotherapy is a hands-down preferred choice (Pearlstein et al, 2006; The Carlat Psychiatry Report, 2013). The fact that IPT is time-limited as well as interpersonally focused makes it an attractive psychotherapy for new mothers with PND (and sometimes their partners).
This article was adapted from Mental Health Academy’s CPD course “Treating Postnatal Depression with Interpersonal Psychotherapy”. The aim of this course is teach participants how utilise IPT as a treatment for PND.
Carter, W., Grigoriadis, S., Ravitz, P., & Ross, L. (2010). Conjoint IPT for postpartum depression: Literature review and overview of a treatment manual. American Journal of Psychotherapy: 2010, 64(4): 373-92.
Chan, A. & Payne, J. (2013). Homicide in Australia: 2008–09 to 2009–10 National Homicide Monitoring Program Annual Report. Monitoring Report No 21. Australian Institute of Criminology: 2013(6).
Cooper, P. & Murray, L. (1995). Course and recurrence of postnatal depression: Evidence for the specificity of the diagnostic concept. British Journal of Psychiatry, 166, 191-195.
Dennis, C.L. & Ross, L. (2006). Women’s perception of partner support and conflict in the development of postpartum depressive symptoms. Journal of Advanced Nursing: 2006, 56(6): 588-599.
Diego M.A., Field, T., Hernandez-Reif, M., Cullen, C., Schanberg, S., & Kuhn, C. (2004). Prepartum, postpartum, and chronic depression effects on newborns. Psychiatry: Interpersonal and Biological Processes: 2004, 67(1), 63-80.
Finkelhor D. (1997). The homicides of children and youth: a developmental perspective. In: Kantor G.K., Jasinski J.L., editors. Out of the darkness: contemporary perspectives on family violence. Thousand Oaks: Sage, pp. 17–34.
Friedman, S.H. & Resnick, P.J. (2007). Child murder by mothers: Patterns and Prevention. World Psychiatry: 2007(6), 137.
Matthews, S.G. & Meaney, M.J. (2005). Maternal adversity, vulnerability and disease. In: Riecher-Rössler, A. & Steiner, M., editors. Perinatal stress, mood and anxiety disorders: from bench to bedside. Basel: Karger: 2005, 28-49.
Mauthner, N.S. (1995). Postnatal depression: the significance of social contacts between mothers. Women’s Studies International Forum: 1995, 18(3): 311-323.
Misri, S., Kostaras, X., Fox, D., & Kostaras, D. (2000). The impact of partner support in the treatment of postpartum depression. Canadian Journal of Psychiatry: 45, 554-558.
Mouzos, J. & Rushforth, C. (2003). Family Homicide in Australia. Trends and Issues in Crime and Criminal Justice No 255. Australian Institute of Criminology: June 2003(3).
Mulcahy, R., Reay, R.E., Wilkinson, R.B., & Owen, C. (2009). A randomised control trial for the effectiveness of group interpersonal psychotherapy for postnatal depression. Archives of Women’s Mental Health: 2010, 13: 125-139. DOI 10.1007/s00737-009-01091-6.
Orenstein, D. (2014). Analysis: 32 years of U.S. filicide arrests. News from Brown. Brown University: Feb 25, 2014. Retrieved on 16 December, 2014, from: hyperlink.
Priest et al, 2005
Roberts, S.L., Bushnell, J.A., Collings, S. C. & Purdie, G.L. (2006). Psychological health of men with partners who have postpartum depression. Australian and New Zealand Journal of Psychiatry: 40, 704-711.
Ross, L.E., Sellers, E.M., Gilbert Evans, S.E., Romach, M.K. (2004). Mood changes during pregnancy and the postpartum period: development of a biopsychosocial model. Acta Psychiatrica Scandinavica: 2004, 109: 457-466.
Schwartz, L.L. & Isser, N.K. (2007). Child homicide: Parents who kill. Taylor & Francis, 155.
Statewide Obstetrics Support Unit (2007). Perinatal depressive and anxiety disorders. Subiaco, Western Australia: Women and Newborn Health Service, King Edward Memorial Hospital.
Stone, K. (2013). What the DSM-5 says about post-partum depression and psychosis. Postpartum Progress. Retrieved on 16 December, 2014, from: hyperlink.
The Carlat Psychiatry Report. (2013). Post-partum depression: Use interpersonal therapy. PsychCentral Professional. Retrieved on 16 December, 2014, from: hyperlink.
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The best gifts for your mother
Whether you love it or hate it, most people will agree that the mother-child relationship is one of the most significant relationships in a person’s life, affecting your wellbeing throughout your life.
At the same time, many of us will not have the perfect relationship with our parents. In fact, one psychologist estimates that 85% of families are dysfunctional. More optimistic estimates say that about half of mothers are “good enough” (not perfect, but adequate). Either way, there are many of us whose maternal interactions were not the intimate safe haven idealised by Hallmark.
Let’s look at some of the ways things can be off and what you can do to create a more rewarding, happy, and healthy relationship with your mother.
Making it better: strategies to improve the dynamic
Perhaps your mother was loving, healthy, and not at all dysfunctional: great! If she sometimes did things that bothered you, but was often “there” for you, you have still done fairly well in the Mother Lottery. But let’s say your mum engaged in what we could call “toxic” behaviours: ways of interacting that didn’t help create a positive bond between you?
These behaviours would be things like being dismissive, critical of your ideas and aspirations, not really listening to you or making everything about her. Some mums were simply caught up in their own chronic pain – either physical or psychological – and just didn’t feel up to the task of caring for their children, even though they loved them deeply. Such mums may neglect their children or make them into their caregivers. Even if your mum is showing (or used to show) some of these less-than-ideal behaviours, she undoubtedly loves you very much and also probably did the best she could. Given that, it may be up to you to make the dynamic better for both of you.
Have a look at the A-B-C-D-E of mother-relationship improvement below. These are strategies of Activation, Boundaries, Communication, Doing stuff, and Empathy.
Activation. 1. Make the first move to get past any estrangement or ill will – she may want to but perhaps does not know how to do this). 2. Change yourself; grow past the point where her criticisms and dismissive comments wound you. 3. Consciously activate a new, more modest set of expectations about what the relationship can achieve. 4. Stick to the present – bringing up old stuff may just re-wound both of you. 5. Repair damage quickly when new misunderstandings arise.
Boundaries. 1. Set boundaries and stick to them. 2. Balance individuality and closeness. 3. Agree to disagree. 4. Don’t bring third parties into any discussions or conflict.
Communication. 1. Be an active listener even if you feel that you were not listened to. 2. Use I-statements rather than accusing her. “I feel this way when...” 3. Talk about how you want to communicate (e.g., no calls after 8:00 p.m. unless urgent) 4. Comment on how some of your best qualities came from her. 5. Ask her what life was like for her at your age, or how she handled things you are dealing with now. 6. Reference childhood family jokes and memories; tell her about the aspects of your childhood that were happy (assuming some were). 7. Tell her you love her.
Doing stuff. 1. Go shopping with her or take her to lunch; spend time with her. 2. Ask her what her favourite movie is; bring it over to watch together. 3. Take a picture of the two of you together; frame and give it to her. 4. Tell her to invite a couple of friends over; make them all lunch.
Empathy. 1. Learn to forgive; 2. Put yourself in her shoes; poor mothers are usually badly mothered themselves. 3. Try to be affectionate.
Some of these strategies may be difficult for you but keep in mind that taking steps to improve relationships with your parents will benefit you as well. New research shows that those who have a strong bond with their parents tend to have lower levels of depression, higher levels of self-esteem, and higher levels of intimacy and satisfaction in their romantic relationships.
Often, the best gifts we can give are not material but are interpersonal in nature. While these types of social gifts may take more time and effort, we often need to work the hardest for the biggest rewards.
Written by Dr Meg Carbonatto B.S., M.A., and Ph.D.
This article was originally published in Asteron Life’s Balance Blog. AIPC regularly contributes to Balance’s wellbeing blog category.
Counselling and the Neurobiology of Personal Experience
The research in neuroscience is highly supportive of counselling’s emphasis on deep listening, empathic understanding, strength building, and wellness (Ivey, Ivey, Zalaquett, & Quirk, 2011). Counselling is shown to change the organisation of the brain: a learning process as the brain responds to stimuli and creates neural pathways to accommodate new information (Ivey, 2009). “Information” includes experiences, actions, thoughts, and cues: both those emanating from within ourselves and those from others and most especially including those stimuli arising within the therapeutic relationship. As John Ratey (2008, in Sullivan, 2012) said, “Experiences, thoughts, actions and emotions actually change the structure of our brains” (emphasis added).
Helping Families Enhance Resilience: Encouraging effective parenting
As the pillars of a family of origin and the ones responsible for the creation of the rest of the family, parents are the prime “movers and shakers” of the family system and all of its dynamics. They know that they are tasked with the crucial function society gives to a family: that of educating and socialising its children. The effective performance of this function serves both the family and the wider society, as well-socialised young people grow into healthy, well-functioning adults who can make positive contributions to their world. As noted, one of the process factors of families that flourish is that they have a legitimate and clear source of authority: that is, a system with established rules and roles, with parents that are effective.
Q&A with Toula Gordillo (Clinical Psychologist)
Q. We have a fourteen year old daughter (Tammy) with Aspergers’ Syndrome. She has difficulty relating to her peers and is awkward in most social situations. She has narrow, often obsessive, interests in a particular thing or person. She wants to make friends and have a boyfriend like her peers, but she often misinterprets important social cues. She speaks too loudly, gets too close, is very direct (sometimes far too direct/insulting) and says things that make her peers feel uncomfortable. How can we help our daughter?
A. Young people like Tammy often talk incessantly and don't know when to stop or don’t know when to speak appropriately. Their peers may not know how to relate to them, and they often don’t appear to have a disability. Young people with Aspergers’ Syndrome (otherwise known as ‘Aspies’) may appear relatively normal in some cases, so their peers may think they are just 'weird' or 'strange'. This sets them up, unfortunately, for teasing and ridicule. Their peers and siblings may think, "He/she is so weird", instead of, "They have a condition and I need to be tolerant".
Parents, teachers and counsellors can help young people like Tammy by teaching them some of the rules of social conversation through telling a story in a role-play. Try to understand that they may be very literal and they need everything explained in a very logical, sequential and ordered way – which can be very frustrating at times. Stories and images can help an ‘Aspie’ to apply the rules of social engagement in a logical way that is consistent with their sometimes ‘quirky’ view of the world!
Tammy’s counsellor role-played the following ten rules of conversation by pretending to be another young person and having a conversation with Tammy. She asked Tammy to imagine the image of her having a conversation with a friend.
The counsellor discussed, and encouraged her parents to discuss, the following:
- When meeting someone for the first time, introduce yourself. E.g., "Hi, I'm Tammy". Politely ask the person what his/her name is. If you see someone you know, address them by name, e.g., "Hi Luke!"
- Smile and use a calm, friendly tone — not too loud and not too soft is good.
- In most cases, stay at arm's length — this is about the right distance in most situations.
- Ask a question about the other person — e.g., "What do you like the most?" "What kind of music do you like?"
- Use good listening skills — make eye contact, nod your head or use "Mmm" to show you are listening. Don't interrupt!
- Ask a question relating to something the person just told you — e.g., always try to ask two questions about the other person before telling them one thing about yourself.
- Take turns talking and listening — don't talk about yourself all the time!
- Look for signs of disinterest — if other people turn their head or body away from you, give you short replies, or refuse to make eye contact with you, then your attempts to communicate are not working. Just say "See you later" and move away.
- Don't change the subject — let the other person change the subject if they want.
- When it is time to end the conversation (because you need to go or there are signs of disinterest), say, "It was nice talking to you!" or "I'll see you later".
If you’re counselling a child/youth has Asperger's Syndrome it can be very challenging! Try to be patient. They are often prone to anxiety (particularly when they are not in their 'comfort zone' and they may find it very difficult to cope with change). They often have other conditions such as ADD/ADHD, depression, learning difficulties, social/emotional trouble and will often need extra assistance to perform regular tasks.
The challenge for parents/carers of 'Aspie' teens and pre-teens is to help them without them feeling like you are telling them what to do. Stories and images i.e., telling them messages through stories to help form an image in their mind, can be particularly helpful for teens and pre-teens with Asperger's Syndrome who may have a very different ‘worldview’ to that of their peers and the wider community.
For more information on how to help teens or pre-teens with Aspergers’ Syndrome and other mental health or behavioural difficulties using stories and images, download a free newsletter at www.talktoteens.com.au.
Toula Gordillo is a Clinical Psychologist, AIPC private assessor/tutor and regular contributor for Institute Inbrief. Toula has an extensive work history as a Clinical Psychologist, Teacher, and Guidance Officer. For more information, visit www.talktoteens.com.au.
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Practicing unconditional self-acceptance and compassion
When discussing happiness, one attitude/belief that deserves special mention is the art of accepting ourselves on an “as is, where is” basis. For us to be peacefully in relationship with our own humanness – our own combination of strengths, growing edges and unique quirks – means to have less stress from the source of our own critical voice. You know the voice: the one that yells at us that we are not _____ (fill in the blank: “slender”, “clever”, “good at business”, etc), or that we have not achieved enough. The more we can truly live from a genuine sense of “I am ok”, the more that we can be in compassionate, accepting relationship with helpees and others.
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Many students of the Diploma of Counselling attend seminars to complete the practical requirements of their course. Seminars provide an ideal opportunity to network with other students and liaise with qualified counselling professionals in conjunction with completing compulsory coursework.
Seminar topics include:
- The Counselling Process
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