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Zimmerman, M., McGlinchey, J.B., Posternak, M.A., Friedman, M., Attiullah, N. & Boerescu, D. (2006). How Should Remission, from Depression Be Defined? The Depressed Patients Perspective. American Journal of Psychiatry, 163(1),148-150. Retrieved January 25, 2006, from http://ajp.psychiatrvonline.org/cgi/contentlfull/163/1/148 248 APPENDIX (I) UNE The University of NEW ENGLAND SdhoolofEducation Armidale, NSW 2351 Australia Telephone [lnt'l +61 2] (02) 6713 5081 / 6773 2560 Fax [lnt'l +61 2] (02) 6713 2445 I 6713 5078 email: education@rnetz.une.edu.au Information Sheet for Participants This document provides information to help you decide whether or not to volunteer to participate in this research project. Please read it carefully before you make a decision. You must be 18 years of age or older to participate. You will not be charged any money nor will you receive any payment for participation in the program. Title of project: The development of an Internet course as an integral component of face-to-face treatment of major depressive disorder (MOD). Names and contact details for persons responsible: Professor Anne-Katrin Eckermann, Associate Dean (Research) Faculty of Education Health and Professional Studies, Director Centre for Aboriginal and Multicultural Studies CRAMS, Faculty of Education Health and Professional Studies, University of New England, Armidale, NSW, Ph (02) 6773 3849, email: aeckerma@une.edu.au Dr John Malouff, Senior Lecturer, School of Psychology, Faculty of Arts, Humanities and Social Sciences, University of New England, Armidale, NSW Ph (02) 6773 3776, email: Jmalouff@une.edu.au Dr Howard Smith, A/Lecturer, Faculty of Education Health and Professional Studies, University of New England, Armidale, NSW Ph (02) 67733109, email: howard.smith@une.edu.au Associate John Jacmon, Consultant Psychologist, 317/410 Elizabeth'St Surry Hills NSW 2010, Ph (02) 9211 1411, email: john@johnjacmon.com Nature and general purpose of the research: The study aims to make psychotherapy for mild to moderate depression more effective and affordable. A self-learning Internet-based course will be used to train clients in skills which are normally covered in 4 to 6 face-to-face sessions. Clients will undertake the course on their own at no cost to them. When they complete the 249 course they will begin one-on-one treatment. The study tests whether the course is capable of reducing treatment costs by about 40%. In the study you will undertake the course on your own, with weekly email contact with the investigator. You may also contact the investigator by phone. If you feel it is important you could also talk to the investigator about a face-to-face session to assist you to understand some aspects which are causing you difficulty. To participate in the project you need to: • suffer from symptoms of depression; • have the capacity to access the Internet in private; • have no currently active psychosis; • not be receiving any treatment for your depression; • be able to devote minimum 2 hours/week to the course; • be willing to practise course advice and skills daily. Research methods used and the nature of your participation: If you wish to participate you need to make an appointment for a session with the investigator. In the session you will be invited to complete a five-minute paper­ and-pencil test on depression. If the results indicate that your level of depression is mild or moderate you will be invited to participate in the project. The investigator will explain the course to you. The course is 14 pages long and is estimated to take about 14 -16 hours to complete, over 4 to 6 weeks. At the end of every session, estimated to take about a week to a week and a half to complete, you undertake some homework and forward this to the investigator by email. About every second week you complete a test on your symptoms and advise the results to the investigator by email. You can also ask the investigator by email for any help you wish. At the end of the course you visit the investigator and complete the same depression test you completed when you were selected to participate. You will also be invited to complete a questionnaire on how useful you found the course and the extent to which you have been using the skills which you have learnt. You then begin your one-on-one treatment of about six sessions. When these sessions are ended you will be invited to complete the depression test and the questionnaire on the extent to which you have been using the skills in the course in your day-to-day life. Three months later you will be invited to return to complete the depression test and the same questionnaire once more. Possible risks, inconvenience or discomfort you may experience 250 None of these are likely. At worst, your depression might not get any better or it may worsen. If this is the case consult with the investigator. The investigator will refer you to your GP to arrange for alternative treatment outside the study. If some distress is caused or treatment raises other issues and you feel the need for counselling outside the project, contact the telephone counselling service (see the front of your telephone directory) or visit the local community health centre. Length of time of project The course should take between 4 and 6 weeks to complete. One-on-one treatment should take another 6 to 9 weekly hourly sessions. A recall will take place three months later. The total length of time is about six months. Your participation is estimated at between 11 and 16 weeks. Leaving the project The project is entirely voluntary and you may leave any time you wish. Confidentiality and storage of data You cannot be identified through your results. The data will be held in a locked cabinet and in password-protected computer storage. No access will be allowed to anyone other than the people named on this form. Five years after the project all data will be destroyed. Any questions? If you decide to participate please retain this Information Sheet. Please feel free at any time to ask the investigator any questions on the project. Project approval This project has been approved by the Human Research Ethics Committee of the University of New England (Approval No HE05/192 valid to 26/09/2006) Should you have any complaints concerning the manner in which this research is conducted, please contact the Research Ethics Officer at the following address: Research Services, University of New England, Armidale, NSW 2351 Telephone: (02) 6773 3449 Facsimile (02) 6773 3543, Email: Ethics@pobox.une.edu.au 251 Consent Form I certify that I am over 18 years old. I have read the information contained in the Information Sheet for Participants and any questions I have asked have been answered to my satisfaction. I agree to participate in this activity, realising that I may withdraw at any time. I agree that research data gathered for the study may be published, provided my name is not used. Participant or Authorised Representative Investigator 252 Date Date APPENDIX (II) Completers' questionnaires on the course Post course questionnaire - 1. Looking at contents and presentation Now that you've completed the course you should be able to assess its usefulness to you. Your ideas are vital to the ongoing development of the course and to gauge whether this approach can playa role in the treatment of depression. The following questions won't take long to answer. At the end you have the opportunity to write comments on areas not covered by the questions which you consider important. To answer the questionnaire read each item. If you: • strongly agree, write 5 in the response column on the right • agree, write 4 • not sure, write 3 • disagree, write 2 • disagree strongly, write 1 No Item Response 1 The text in the course was easy to understand 2 The sessions had too much material for my level of concentration 3 The sessions had too little material to keep my interest 4 The material was boring 5 The way the material was presented in the course was enjoyable 6 Reflecting on the pictures on the top right of the pages helped me feel better 7 The humorous pictures made me smile 8 The sites with more information that I looked at were useful 9 The games and puzzles that I did helped me relax after each session 10 I skipped many of the information sites 11 I skipped many of the game sites 12 Completing Goldberg helped me measure my progress 13 The exercises helped me to apply the skills I learnt in the sessions 14 The exercises took too long to do 15 The exercises were not long enough 16 Emails enabled me to communicate adequately with my psychologist 17 Even though my psychologist wasn't physically present I felt I had his support 18 I came close to giving up on the course 19 Looking back on the course, I am glad I did it 20 Revisiting the course should help me avoid depression in the future 253 Response Post course questionnaire - 2. Looking at skills and tasks The course aimed to train you in the application of key skills and to encourage you to go against the symptoms of depression by undertaking particular tasks. The items below include some of the skills and tasks. Consider each item in turn. If you are applying the skill or undertaking the tasks: • as often as you need to do so, write 5 in the response column • more often than not, write 4 • about half the time you need to do so, write 3 • less than half the time you need to do so, write 2 • hardly ever, write 1 No Skills/tasks 101 Avoiding isolation - communicating with family, relatives, friends 102 Exercising - walking, gym, sport, swimming, etc 103 Getting up at your usual time 104 Going on with your daily activities 105 Breathing relaxation 106 PMR 107 Basic meditation 108 Mini meditation 109 Relaxation activities such as reading, humorous videos, etc 110 Taking supplements such as vitamins, fish oil, etc 111 Following a good diet 112 Identifying negative thoughts causing a downward mood 113 Challenging negative thoughts with 'where is my evidence' 114 Challenging negative thoughts using Aristotelian logic 115 Persevering with thought challenging until the mood improves Your comments on course: 254 Post-sessions questionnaire - looking at skills and tasks The course aimed to train you in the application of key skills and to encourage you to go against the symptoms of depression by undertaking particular tasks. The items below include some of the skills and tasks. Consider each item in turn. If you are applying the skill or undertaking the tasks: • as often as you need to do so, write 5 in the response column • more often than not, write 4 • about half the time you need to do so, write 3 • less than half the time you need to do so, write 2 • hardly ever, write 1 No Skills/knowledge 201 Avoiding isolation - communicating with family, relatives, friends 202 Exercising - walking, gym, sport, swimming, etc 203 Getting up at your usual time 204 Going on with your daily activities 205 Breathing relaxation 206 PMR 207 Basic meditation 208 Mini meditation 209 Relaxation activities such as reading, humorous videos, etc 210 Taking supplements such as vitamins, fish oil, etc 211 Following a good diet 212 Identifying negative thoughts causing a downward mood 213 Challenging negative thoughts with 'where is my evidence' 214 Challenging negative thoughts using Aristotelian logic 215 Persevering with thought challenging until the mood improves Your comments on the face-to-face sessions: 255 Response Post-three months questionnaire - looking at skills and tasks You completed the course some months ago. In the sessions you practised applying key skills and knowledge in your day-to-day life and you were encouraged to continue to do so. Please complete the following questionnaire on the extent you have been using the following skills and knowledge in the past two weeks. At the end you have the opportunity to write comments on the whole treatment procedure. Consider each item in turn. If you are applying the skill or undertaking the tasks: • as often as you need to do so, write 5 in the response column • more often than not, write 4 • about half the time you need to do so, write 3 • less than half the time you need to do so, write 2 • hardly ever, write 1 No Skills/knowledge 301 Avoiding isolation - communicating with family, relatives, friends 302 Exercising - walking, gym, sport, swimming, etc 303 Getting up at your usual time 304 Going on with your daily activities 305 Breathing relaxation 306 PMR 307 Basic meditation 308 Mini meditation 309 Relaxation activities such as reading, humorous videos, etc 310 Taking supplements such as vitamins, fish oil, etc 311 Following a good diet 312 Identifying negative thoughts causing a downward mood 313 Challenging negative thoughts with 'where is my evidence' 314 Challenging negative thoughts using Aristotelian logic 315 Persevering with thought challenging until the mood improves Your comments on the entire treatment process: Include in your comments whether you are confident that you have the skills to prevent depression in the future. 256 Response ~iiiipiiiiraiiiiciiiitiiiiiSiiiiiniiiigiiiiliiiiOiiiiOiiiikiiiiiniiiigiiiiaiiiit iiiit hiiiiiniiiigiiiiSiiiiidiiiiiiiiiiffiiiieiiireiiiiiniiiit liiiiiy~iillllill CBT • The Basics A young or an old woman? Both!! Click here If you want some music to help you reflect click on two Scott Joplin classics Bethena It's a warm summer's day and you have some spare time. You take a trip to the bush and come along this waterfall. Put yourself in this scene. Try to imagine how relaxing it is. Spend as much time as you like imagining how good it feels. (Microsoft clipart) 257 Example 3: the crime rate. We hear daily about criminal activities and become angry, concerned or apprehensive. We do not often think of the large numbers of people who derive their income legitimately from crime: police, courts, lawyers, etc. Example 4: we experience a downturn, for example we lose our job. We think that it will be hard to find another and that we will not be able to make ends meet. We feel panicky, sad and blame ourselves for our misfortunes. Or we might think that with our skills and experience we shouldn't find it too difficult to find another job. We feel positive. We start job hunting. Illusions are a good way of making us realise that we have the ability to see things in different ways. Click on the sites at the right and enjoy the illusions. Ok, by now you have the idea. Click on the link test on looking at things differently. You can look at practically everything in life in different ways. Let's practise by thinking of some examples. You're going to enjoy this part! Example 1: you hear suddenly an ambulance going by with sirens blaring. You think that something bad has occurred. You feel apprehensive. Your stress levels rise. Or, you might think that someone in need of help will have it soon. You feel relieved. Your stress levels do not rise. The choice of which way to think is yours! Example 2: you are driving along a freeway. You notice a young driver weaving in and out of traffic and cuts right in front of you causing you to brake. You might think that the young driver is reckless and has almost caused an accident. You feel angry. Your stress levels rise. Or, you might think that since nothing happened let it go. Your stress levels do not rise. symptoms of stress (I) Meditation CST tools (I) CST tools (II) Beating your depression The symptoms of stress (II) key CBT concepts Analysing thoughts Looking at things differently Practising looking at thl.sdlfferently Write four different examples of looking at things in different ways (don't send the email yet!). Click on Goldberg Depression Inventory and do the test. Enter the score in the email and send it on its way. Once you have done that, you have finished the first module of the course. Now it's time for a little relaxation. Reflect on the waterfall scene at the top right of the page. Then on the bottom right you will find the site for a simple yet absorbing game. Try it. If you haven't had enough, try some of the other games. Be careful - they can be addictive!! John Jacmon Phone: (02) 9211 1411 Fax: (02) 9280 4376 Suite 317, 410 Elizabeth St SURRY HILLS 2010 and at Glenfield 258 For some fantastic illusions click on: CO(I~!l'~t$jLQJil:5?iu1\s Illusions 2 More?Click on G ..alTl.es Games you can plan and enjoy at the Appendix IV Case Study Details (a) Aaron Aaron was first seen on 9 September 05. He is a male Caucasian, in his 40s, working as a youth counsellor. He has had depression on and off for several years caused by an unpleasant childhood, several life difficulties including failed partnerships and unsatisfying work. He began a university course in psychology but his depression worsened with the added study pressures and he withdrew. The withdrawal served to reduce further his already low self-esteem. He considered his life had been at a standstill since his thirties and he could not think of too many happy moments in the past. Aaron had been on antidepressants for several years. He was disheartened by his many failed attempts to lift his depression. In a moment of clarity he realised that he had not experienced any improvement notwithstanding that he had been taking the medication for a considerable time. He reasoned that this method of treatment was inappropriate for him. It had not helped him to think through his challenges and find a way out of the distress that had been plaguing him for much of his life. He heard of the writer's program through a psychologist friend and visited his GP for a referral. In the introductory session Aaron stated that he was glad to be included in the study. He was attracted to the intervention because it gave him the opportunity to take charge of his own treatment and at the same time have a 'guardian angel' as he termed the writer in his role as the treating psychologist. He raised his wish to become a psychologist himself and said that in his work he was sought for assistance by the most troubled young persons. The writer encouraged his aim to become a psychologist and agreed to discuss at a later time practicalities including availability of external courses. Aaron was in shift work which varied from week to week and was therefore not in a position to attend classes. In the session Aaron, as with all other participants, was briefed on the program and advised that he could seek face-to-face sessions at any time he felt the need in order to overcome difficulties impeding his progress. 259 He was advised that there were two distinct treatment phases namely the Internet course which he would complete on his own with email support for submitting assignments and depression test assessments, receiving marked assignments, overcoming 'stuck' points, and arranging face-to­ face sessions with the writer for remedial training. The course consisted of 14 modules each of which was designed for completion in one or two hours. Modules could be completed at one time or spread over several times to accommodate his personal circumstances such as availability, concentration span and mood at the time. There were nine periods in the course at which results of exercises, Goldberg scores and mood monitor evaluations were reported. Emails were the main means of communication though in urgent cases (for example persistent suicidal ideation) he could call the writer by phone. As a guide two modules could be completed every week. Aaron was advised that the purpose of the sessions was to help him overcome 'stuck points' during the course and to hone the skills learnt in the course following completion in a face to face setting. The sessions during the course were remedial and were not meant to replace the course itself. In the first session after the course the SOl and the HDRS would be completed to gauge progress and also to provide information on the need if any for remedial work. A recall session was planned for three months after the end of the sessions to test for any symptoms of depression. He had Internet access and was about to get broadband. Aaron completed the SOl scoring 27, just below the 'severe' cut-off. Assessment on the 21-item Hamilton Scale produced a score of 26 placing his depression at the moderately severe level. Aaron's mood lifted by the end of the session as he realised that he now had an opportunity to address his depression without drugs in a way that blended with his employment activities and also gave him an insight into the work of a psychologist. 'First time I'm feeling positive about getting on top of my depression' he said as the session ended. 260 He returned the first Goldberg score and mood monitor on 23 September 05. The Goldberg score was 43, denoting moderately severe depression. The mood monitor showed an average of 5.7 (O=bad, 1O=good) with little variation over the three days and the three daily occasions. In his accompanying email he said: Hi john. Sorry to have taken so long to start. Been byssi with work, also a large dose of procrastination and possibly avoidance. Sometimes I suspect I like to be stuck. But I feel and am determined that these three things/qualities (procrastination, avoidance and stuck-ness) are slowly dissolving, to be replaced with a sense of achievement, well-being and flow. Correspond soon John. On 29 September 06 he completed the requirements for the second reporting period (modules on theory and practice of looking at things differently). Though at this stage his depression continued at clinical levels responses to the exercises on looking at things differently revealed considerable insight into the principle, for example: A tramp is walking into a small village as night is just falling. He sees a window with a man looking out sipping a drink with a soft warm firer light glowing behind him. The tramp thinks how nice it would be to have your own home, possible a family to share dinner with. A man is sitting at a window looking out at the road leading out of the village. He has just lit fire and is sipping a Whisky, he's exhausted. He has been working 12-hour days 7 days a week his business is on the brink of bankruptcy. His wife has asked for a divorce. He sees a tramp walking into town he thinks wistfully to himself how wonderful it would be to have nothing to worry about, to be unencumbered free to go were ever you please with no one to account to. 261 His insight led him later to apply the principle to his own behaviour and hence to reduce his depression. Aaron had experienced many bouts of depression over the years. There were two relapses whilst on the course. The relapses caused him to take 21 days to complete the requirements for the third reporting period composed of module 4. He took 27 days for the fifth, consisting of modules 7,8 and 9. That is, two reporting periods took 48 days compared with 67 days to complete the requirements of the remaining six periods. The writer contacted him by email on 9 October 05, during the third reporting period: Hi Aaron! Haven't heard for a while from you. Just like to reiterate if you think you would benefit from a face-to-face session or two at this stage pis ring and we'll make arrangements! No drama, part of the program! Cheers John J No response was received to the email so the writer rang him a week later. Aaron replied that he was recovering from a relapse and hoped he would soon get back to the module. He submitted the third reporting period requirements eleven days later and the fourth a week after. He made arrangements for a session on 28 October 05. In the session Aaron commented that he had difficulty concentrating and applying the principles he had learnt to date. He asked to practise the Epictetus principle of 'looking at things differently' in relation to a number of 'road blocks' he raised and succeeded in demolishing them. At the end of the session he said 'I feel better. I'm back on track and I can stay that way' 262 His improved mood is demonstrated in his responses to the exercise on thought challenging submitted on 7 December 05: the challenge I faced [ before the course] was to recognize the negative slant and then consciously focus on my abilities and strengths as apposed to my weaknesses. And one of the more critical abilities to cultivate is the ability to be aware of my weaknesses I vulnerabilities but not let them dominate. And critically to get help and support to overcome or compensate for them. Aaron needed two more sessions to help him consolidate his knowledge before he submitted the fifth module. From then on he progressed well and finished the course on 12 January 06, taking 125 days, more than any other participant. There was a minor relapse over Christmas and New Year but he was able to address it effectively. In a session held on the day he concluded the course he said 'Looks like I'm stuck with thought challenging for life...not that I mind 'cos it seems to be working.' Aaron had more face-to-face sessions than any other participant to address 'stuck points'. He needed nine sessions two of which were devoted to pre- and post-course assessment. Completers took an average of 4.67 sessions. Of Aaron's six treatment sessions three were required mainly to help him through a major relapse suffered during the fifth reporting period and to assist him to continue on the course because his concentration was low. The sessions addressed 'stuck' points which prevented progress and understanding. The effectiveness of the sessions in helping him through the relapse is evident in his relatively good score on Goldberg of 22 in the fifth reporting period, denoting mild to moderate depression, down from 38 two months earlier. In his session at the end of the course on 12 January 06 Aaron revealed that he had begun to achieve a progressively deeper understanding into the mechanisms of addressing his depression from about the sixth reporting period onwards (23 November 05). In this time he began to 263 learn negative thought challenging using Aristotelian logic and Socratic questioning. He gained expertise in applying the Epictetus principle, namely 'looking at things in different ways'. In a session on 24 November 06 he said that he was beginning to realise that by applying the skills learnt on the course he could actually influence the direction of his mood. The more frequently he challenged his negative thinking the better he began to feel and the more adept he became in using the process. He added that he established an ever strengthening and closer link between stimulus (an event triggering negative mood), response (thought challenging) and reinforcement (feeling better). It began to dawn on him that managing his mood was within his grasp. Up to now he had felt that it was a task beyond him and that he could not possibly do it. He said 'The more I challenge the easier it gets.' He considered his key tools were negative thought challenging and looking at things differently. The results of his efforts are indicated in a reduction in his Goldberg score from 22 on 23 November 05 to 10 on 12 December 05 and 7 on 21 December 05, at the end of the course. That is, the end of his last relapse which occurred in the fifth reporting period was followed by a period of rapid improvement which accelerated at first and then settled to non clinical levels by 12 December 05. His improved mood was exemplified in his responses to a behavioural exercise which posed the scenario of returning to an experience (writing a journal of his life situations) which he had been avoiding because of his depression: What were your thoughts? I can do this. It won't be hard. All I have to do is start and blurb about anything What were your feelings? Feelings of excitement combined with a little hesitance and procrastination What did your body want to do? To start doing it. I still have a few aches when a sit for a while but I know that is just something I can manage 264 When he arrived on 12 January 06 for end-course testing he said that he had a relapse for a few days and his symptoms of irritability and low mood arose. He calmed down, revised sections of the course, resumed thought challenging and his mood improved. He said that he learnt that he could not afford to neglect negative thought challenging any time his mood became depressed because he risked a relapse. He was determined to practise thought challenging until it became an integral part of his behaviour. In the session he reported no clinical depression symptoms and his mood was positive. The SOl score of 0 and the Hamilton score of 3 supported the absence of clinical depression. He had been advised by the university that his application to study psychology had been approved. He wanted to orient himself to the discipline by reading articles on the Internet and we discussed suitable sites. Aaron sought one session about a month later to ensure that he continued free of depression and to address any potential triggers which might have arisen in the meantime. Aaron attended the session on 9 February 06. His freedom from clinical depression was maintained. He maintained the same score for the BOI as for the 12 January testing. The Hamilton score was 5. Both scores indicated no clinical depression. He had launched into his studies by reading articles in various areas of psychology. We discussed fields of particular interest to him such as disturbed adolescents and drug addiction. We agreed to meet in three months to evaluate progress. We met on 4 May 06 for the three-month follow-up. He presented in a positive mood as in the last two sessions. He had begun his studies and was progressing well through the assignments. The SOl and Hamilton scores of 6 and 5 respectively indicated no clinical depression as for the previous two occasions. 265 Aaron considered himself out of depression and was thankful for the program. He commented 'it's been a long time since I had no depression. It's a great way to treat'. Key factors of participant experience History: long-term depression, ineffectiveness of antidepressants Attractions to online study: in charge of own treatment, face-to-face sessions, blend with life Relapse: yes and recovered Significant component: Epictetus principle (looking at things in different ways), negative thought challenging Behaviour change: lifted depression and began University course (b) Bill The second participant, Bill, was first seen on 9 October 05. He presented in a depressed and anxious mood. He had been seeing his GP for depression and had been taking antidepressants. After a few months he did not consider that he had improved and could only see a negative connection between feeling sedated and applying his thinking to resolve the problems that had amassed in his personal life. He spoke to his GP who referred him to the writer for psychological treatment. Bill was a graduate in his late 20s who held a busy and stressful executive position in the air transport industry where safety was of a paramount consideration. He was a shift worker and he felt that his depression had led to deterioration in his work performance. He perceived that he was becoming increasingly slow in responding to urgent situations. He feared that he might not foresee or anticipate a looming serious problem and thereby not be able to prevent a disaster causing loss of life as well as cargo. Bill was married to woman of Asian background who had migrated to Australia some 10 years ago. She made little effort to acculturate and was depressed for much of their marriage notwithstanding considerable efforts by Bill's mother and brother to befriend and support her. The 266 couple had a small boy with whom Bill felt very close - the boy gave him his only joy in the family. The boy mainly spoke his mother's language at home, at her insistence. Bill revealed that sex between the couple had ceased some time ago and his wife was increasingly distancing herself from her husband. On the pretext that she needed to be close to their child at night because of his night terrors she would sleep in the same room as him. She would devote about an hour a day to talking to her parents overseas. Communication between the couple was sparse and confined to essentialities. The family situation and work pressures appeared the key factors driving Bill to depression. In the session Bill readily saw the resolution of his family problems as paramount to his returning to a state of wellbeing. He felt that once his depression was under control his work performance would improve. His goal in treatment was to gain the clarity of mind needed to reach a decision concerning his future in his family. He had been thinking about breaking up but could not come to terms with the intense guilt feelings raised by his perception that he would be abandoning his child. His need for help intensified following a decision by his wife to visit her parents for an extended period and take their son with her. She said that she intended to return but Bill needed to clarify in his own mind whether he would be prepared to continue with the marriage. She left with their son soon after Bill's session. Bill was attracted to the concept of the Internet training course because he could progress through the modules at home between shifts and fill some of the hours of loneliness without his child. Integrating the course with sessions by a live therapist was comforting because it meant that he could take the opportunity to ventilate over his difficulties with a professional with whom he had established a relationship through the Internet course. During the sessions and in his emails he showed that he was an experienced computer and Internet user. Bill's initial BDI score was 28, which was at the cut-off between moderate and severe depression (Beck, Steer, & Brown 1996). The Hamilton test score of 29 indicated moderate severe depression (Hamilton 1960). Bill 267 returned the first Goldberg and mood monitor scores on the same day. The scores were 60 (severe depression) and 5.9 ranging from an average of 5.3 in the morning to 6.3 at noon and 6.0 in the evening. At that time he was working a normal day shift. The mood monitor scores indicated that his depression was worse in the morning as he was bUsy getting ready for work but improved as the day progressed and he became absorbed in his work. At night he avoided a larger regression in mood because he would put on his favourite music and enjoy a glass of wine as he visited different sites on the Internet. Bill took 31 days to complete the course and he attended six sessions. The longest interval between reporting periods was 7 days for the fourth period, namely modules 5 and 6 (stress symptoms). He completed the modules in the first three reporting periods (Epictetus and introduction to stress) in eight days after he began the intervention. His second face-to­ face session was on 19 October 05. In this session he presented in a surprisingly good mood compared when first seen. Bill had completed and submitted modules 7, 8 and 9 (relaxation and meditation) on that day. He found that he had little difficulty in understanding the content of the modules and especially in putting the Epictetus concept (looking at things differently) to work in his day-to-day life. He wanted to use the session to help him clarify options about his marriage, which was a major precipitating factor in his depression. He realised that he needed to change the conditions under which he was living in order to feel happy and that his own unhappiness was likely to be affecting his boy. We worked through several scenarios. By the end of the session Bill had prepared a list of what he saw as issues in the marriage which he and his wife needed to resolve. He decided to speak to his wife about the issues next time they talked to each other. If after she thought about them she was not willing to work towards their resolution he considered that the option of breaking up the marriage was the more logical one. Bill had experienced a marked change in mood in the 18 days between the first two sessions. He said that being able to follow a program of 268 treatment which was taking him on the road to improvement was what he had been looking for ever since he consulted his GP. He found the Epictetus principle a major factor - he had not realised that a simple-to­ apply principle could make such a difference to his mood. He worked hard at applying the principle in his day-to-day behaviour until it became virtually automatic, like driving. As he said, the more he perceived alternative and less gloomy explanations for situations that confronted him the better became his mood. He noticed the change in his behaviour at work; he no longer felt that he was performing below expectations and was being criticised. He considered that he was becoming more self­ directing and assertive with the result that he felt good about his performance. He was complimented by his superiors because of his handling of an incident in which he took decisive action and prevented considerable disruption and financial loss to the company. He was convinced that had he been feeling as depressed as he was before beginning the course, he would not have been able to come up with the same result. Changes in Bill's Goldberg scores mirrored his perception of improvement. In the first eight days his score fell from 60 to 45, representing a category change from severe to moderate severe. It was maintained at 45 during the next seven days. A further three days later the score reduced to 27, at the low end of the moderate severe category. By that time he had learnt to apply the Epictetus principle in a range of different situations. His responses to an exercise on looking at things differently 9 October 05 demonstrated his grasp of the principle: Driving to work I am pulled over in a bunch of cars for an RBT test. This causes me to arrive late to work. However, a driver within the bunch is found to have been drinking and had he/she not been pulled over and caught, could have caused an accident causing injury, or worse, to myself, my family or others 269 Bill attended a session on 19 October 05 to hone his skills on thought challenging. By 22 October 05, when he had completed studying thought challenging the Goldberg score had reduced to 18, placing his symptoms in the mild category. The score reduced to almost below clinical levels by 6 November 05. His responses to thought challenging exercises in an assignment forwarded on 6 November 05 revealed his improved mood: (Challenge the following thought): There's no future for me: (Response): I have plans for my future, which I want to achieve. There is a future for me It's hopeless - I'm trying to look on the positive side of everything nowadays. There is always hope. Can't do to improve things - I am trying to overcome my depression, and with that a lot of other things will improve in time also It's my fault. - It's not my fault, I will take responsibility if it is my fault, but not otherwise. Bill ended his course on 9 November 05. He came in on the same day for his end course session. The BDI (score 4) and the Hamilton (score 2) showed that depression symptoms were few and at a subclinical level. Bill remarked in the session that the site was like an insurance policy for him. 'It's there when I need it'. When he wanted to revise various concepts he could revisit the site. To ensure that he always had access to the site he downloaded it to his computer. Bill's marital problems continued contributing to his continuing depression and seemingly negating the effectiveness of the intervention. Following a face to face session Bill employed the principles learnt during the intervention which assisted him to make decisions with which he was comfortable and this assisted his recovery from depression. For example he reviewed his functioning at work by asking himself 'where is the evidence that I am not doing well?' The objective evidence he could 270 muster confirmed that he was performing well. His confidence in his abilities returned. He was going out more with friends and enjoying himself. He had spoken to his wife and no longer felt insecure in doing so. He had a few words to his son, which raised ambivalent feelings. In one sense he was happy to have spoken to him. In another sense he felt pangs of gUilt about the likelihood of initiating a break in the family which would leave his son growing up without day-to-day contact with his father. The situation was all the more disconcerting because his former wife would likely return to her parents overseas with their son. He and his son would therefore be residing in different countries. However he was becoming willing to pay this price to achieve his own happiness and he reinforced his reasoning that his son would be spared the pain of growing up in an environment without love between the parents. Bill's earlier doubts whether he would ever have an opportunity to meet a woman with whom he could remake his life seemed to be fading. The insecurity he faced within his marriage appeared to have been metamorphosed into a growing confidence that he had much to offer to a partner in a relationship. He felt that the need for a future relationship to accommodate for contact with his son should not be a significant issue. Bill wanted to attend further sessions because he did not want to risk the continuing problems surrounding the breakup of his marriage leading him back to depression. Bill attended a session on 16 November 05. He wanted to discuss his latest thinking on the option of breaking up his marriage. He mentioned that he had suffered a minor relapse after the real estate agent managing the unit which the family rented informed him that the owner wanted to move in. Bill and his family had to vacate the unit in two months. He felt somehow that this event was forcing him into a decision to break up. He challenged his thinking and reasoned that he had been considering separating for some time and that the notice to move was coincidental. In any case, separation from his family meant that he had to move. He consequently saw the notice differently, as a positive event. It motivated 271 him to look for more suitable accommodation at a time before his wife and son returned rather than leave it to the last minute and risk having to settle for a less desirable place and going through the pain of last-minute packing and moving. Bill's mood lifted in a day or two and he returned to enjoying his recovery from depression. Bill attended another session on 4 December 05. He was more positive and self-confident than in the last session. He had extensively used the concept of looking at things differently to help him see events in his life as challenging rather than daunting. He advised that his wife was reluctant to negotiate changes in their relationship and as a result he had made up his mind to end his marriage. Probably related to his decision is that he met a woman with whom he could see the possibility of a future together. She fUlly accepted that he had a son and supported his lifelong commitment to his child. We discussed the desirability of prioritising the ending of his marriage and letting the formation of any new relationship proceed at its own course, without accelerating it to the extent that it added to the difficulties with his marriage, for example his wife thinking that this woman had taken her husband away. Bill agreed though he was obviously happy at the developments in his life. In an email on 21 December 05 he outlined the results of a discussion with his wife in which he asserted his needs and which brought him closer to the ending of his marriage: Hi John, Please excuse the late reply. Was stuck in Hong Kong a little longer than anticipated. Have created my wish list, of which have started to discuss with the wife to no avail. She only agreed upon point 2. The others turned into a blazing row. 1. Sex life 2. Quality Time - alone 3. Sleeping arrangements 272 4. Communication I feel these are my main points of concern. Any suggestions????? Will see my GP about the new referral shortly. Today's Goldberg - 17 best regards On 18 April 06 Bill was contacted for his three-month follow up scores. His BOI score was 5 and Hamilton was 4. No depression was noted. He advised that his life was going well and that he was proceeding with formal separation from his wife. Key factors of participant experience History: depression due to continuing marital problems, ineffectiveness of antidepressants Attractions to online study: in charge of own treatment, face-to-face sessions, treatment blends with life Relapse: none Significant component: Epictetus (looking at things in different ways) Behaviour change: problem-solved marital issues, work performance improved. (c) Cathy The third participant, codenamed Cathy, was an Asian woman in her mid 20s. She was a graduate from a Sydney university and was undertaking a master's research program. Her bachelor degree was in computing and economics. She had a part-time job, which mainly served to give her an activity outside of her studies. Cathy came from a well-to-do family who operated a large export concern in several countries in Asia. Cathy had no relatives or friends in Sydney when she arrived except for an uncle. He was old, not particularly communicative and had no family. As a result she became lonely in Sydney. She was sensitive about her perceived insufficient fluency in daily English and tended to isolate herself from her fellow students. A few months into her studies she met a 273 student from another Asian country and the two became close. She fell in love with him and without telling her parents she invited him to live with her. The couple did not take any precautions in having sex and she became pregnant. She realised that she could not continue with her studies and look after a child. She decided to have an abortion. This made her feel guilty because of her perception based on her Catholic upbringing that she took a human life away. She did not reveal the abortion to her parents not to anyone else other than her partner. He was not interested in helping her through the emotions that accompanied the abortion. He did not give her any support and lay the blame on her, telling her that she should have taken contraceptives. Apart from his lack of support he was a gambler who frequented the blackjack games at the Casino and played poker machines at clubs and hotels. She began to gamble herself and soon became addicted. He often borrowed money from Cathy to feed his habit, which he did not repay. Gradually Cathy's funds dwindled and she was afraid to ask her parents for an increase in her allowance lest they find out about her partner and her abortion. She gave up her part-time job. These difficulties led her to feel increasingly depressed and they took their toll on her academic work. Even though she was a brilliant and highly motivated student she was increasingly losing her interest. She would spend hours ruminating about her fate and feeling dejected. Unbeknown to her, her partner had become associated with an Asian criminal gang operating at the Casino. He was arrested, charged with fraud, convicted and imprisoned. Cathy was arrested though later released. She became devastated at having had her place searched by the police who also questioned her on several occasions. She feared that she might be deported. Moreover she had lent him a considerable amount of money, which she realised that it was unlikely ever to be returned. The guilt feelings emanating from the abortion did not abate and continued to plague her. She did manage to tell her parents of her plight. They became upset because she betrayed their trust and this added to her distress. She was close to abandoning her course and returning with shame to her parents. 274 She heard about the Internet course through a psychologist friend and made arrangements to attend a session, which was held on 2 October 05. She presented in a depressed and disheartened mood and was at a loss to know what to do. She was attracted to the concept of treatment through the Internet because she was an experienced Internet user and had a particular liking for information technology. A further attraction was the capacity to integrate treatment with her day-to-day functioning. Where study pressures permitted she could devote more time to the course. The faster she progressed through the course the qUicker she would improve in her mood and self-direction. The availability of a live therapist was of lesser importance to her because she preferred to undertake activities on her own though she appreciated the 'insurance' that this provided her. Cathy's BDI and Hamilton scores were both 28. A few days later she advised her Goldberg score was 44 (moderate severe) and her mood monitor averaged at 4.7. This varied from 5 in the morning to 4 at midday and 5 in the evening. The drop in the midday score she attributed to her battle against low concentration in her studies and the demoralising effect it had on her. Cathy took 44 days to complete the course. Apart from the initial and the after-course assessment sessions, she attended one other. This was on 10 November OS, just after she finished the course. The purpose of the session was to enable Cathy to check on her techniques in thought challenging and to discuss her perceived options about a range of personal problems that accumulated in the last few months. Her depression had by now lifted. Her BDI and Hamilton scores were at subclinical levels. Cathy was a self-learner. She completed the course with little email help from the writer. On 9 October 05 she provided responses for the first two reporting periods (modules 1, 2 and 3). Her first Goldberg score was 44, denoting moderate severe depression. Her second Goldberg was 25, 275 just within the mild cut-off. In the same period her mood monitor scores rose from an average of 4.7 to 6.1 further indicating a marked improvement. In her session the day afterwards she remarked that she found the principle of looking at things differently easy to understand and apply. She practised its application as often as she could and she was surprised the difference it made to the way she felt. In her responses to the exercises on looking at things differently she gave the following examples: "I had quit my job because I was unable to cope with my gambling addiction, but now I see it as an opening for me to get a new job, because if I hadn't quit my previous job, I won't push myself so hard to find a better job". "After my arrest, instead of thinking that my whole world is falling apart, I think of it as a chance to reflect on what I had done wrong and how to make my life better". "My bail conditions banned me from going to gambling venues, instead of feeling restricted, I think it is refreshing that I am not allowed to gamble anymore." Ten days later, after she completed module 10, Cathy reported a Goldberg score of 21 indicating mild depression. However, Hher steady improvement took a bad turn. Her responses to the behavioural exercises revealed her mood. (1) Think of the last time you felt really down. Today, felt really down, but no reason, maybe just the same thoughts about sentencing. (2) Can you recall some ofyour automatic thoughts? Sometimes when someone is really nice to me, I automatically think that they have bad intentions to be nice to me. 276 (3) Can you recall some ofyour behaviour (what you said and what you did)? If someone I just met is really nice to me, I automatically back off. (4) Now, with 20-20 hindsight, were our automatic thoughts realistic or slanted negatively? I think it's more slanted negatively, but I can't help it. In an email on the same day she wrote: I'm trying so hard to think positive, but sometimes it's so hard, especially the thought of me working so hard and in the end it will all go down the drain. The writer rang to ask her what made her feel negatively. She explained that she had begun to think that she might be jailed (this was before the charges were dropped) and fail at University; her stay in Australia would therefore be a waste of her parents' money and worse of all that she no longer had their trust and was therefore not a good daughter. The writer gently told her to consider whether she was catastrophising and to find evidence for any of her fears. Cathy realised what she was doing and began to feel a little better. Three days later, on 22 October 05, she emailed 'Dear John, Feeling better today, Thanks'. A week later she emailed 'Almost finishing!' The next day she reported a Goldberg score of 21, placing her depression in the mild category. In her post-course session on 22 November 05 held by phone because she was working long hours, she gained a score of 5 in the SOl and in the Hamilton, both within the subclinical level. Cathy's improvement appeared as she began to come to terms with the Epictetus principle though a temporary relapse did follow. In her post­ course session she admitted that her aim was to work speedily through the course and hence did not seek more face-to-face sessions. However 277 she appreciated having the opportunity to attend sessions with the writer in case she needed help. Her temporary relapse occurred before she covered negative thought challenging based on Aristotelian logic. However the principles she had learnt by the time of her relapse should have helped her out of her sliding mood. Her progress suggested that she may have worked too qUickly and not have given herself enough time to reflect on the principles learnt before she advanced on the next module. Another reason appeared to be that she did not seek enough face-to-face sessions during the course, in which she would have been helped to embed her knowledge and hone her skills. Cathy did not require any sessions after the course. Evidently she understood the concepts presented in the online course and did not require any remedial assistance. She was contacted on 15 February 06 for follow-up testing a week later. Cathy stated that she was working six days a week to save enough money in order to be a lesser financial burden to her family. We agreed we would do the testing over the phone on 22 February 06. The SOl score of 6 and the Hamilton score of 3 showed no clinical depression. Cathy said that her life had been more settled and she had been ruminating less about her distressing recent past. She accepted that she would never see the money she had lent to her former boyfriend and no longer stressed over the loss. She resolved that she would work as many hours as possible in a mobile phone retail outlet in a large shopping centre selling phones and accessories on commission. In the three months since our last contact she had managed to save close to $10000, the same amount of money lent to her boyfriend. There were many times when negative thoughts came to her mind about the past. She would challenge them by saying to herself that she could not change what happened and there was no point going back over past events. She commented that looking at things differently and negative thought challenging were the main tools which she gained in the course. She felt the course continued to help her because every now and then she would go back to the site to follow up some of the referred sites or just to improve her knowledge on some aspects. Having 278 the course available was a safeguard for her and she was glad she completed its requirements. Key factors of participant experience History: depression due to loneliness, damaging relationship, association with criminal activity Attractions to online study: Internet user, liking for computing, in charge of own treatment, face-to-face sessions available if needed, treatment blends with life Relapse: recovered Significant component: Epictetus, Aristotelian logic challenging Behaviour change: resolved issues, continued with University course (d) Dee The fourth participant, Dee, was in her early 30s. She was a counsellor employed by a large charity and was pursuing a qualification in youth work. She was married at one time and had three children, now aged 8, 10 and 12. Her husband was a violent drug addict who frequently abused his family and assaulted her in front of her children. One day, in a rage fuelled by drugs and alcohol he attacked her with a knife and inflicted serious injuries on her. He was charged by the police and imprisoned. The many beatings and the serious injuries she suffered took their toll on Dee. She was markedly traumatised. Dee, at a moment of weakness, which she was to regret later, allowed herself to be convinced that she was currently in no position to look after her family and that she should allow her parents to become the children's foster parents. Dee became calmer with time and turned her attention to herself. She applied to Victims Services (NSW Attorney General's Department) for treatment as a victim of crime and was allocated to the writer. She was diagnosed with posttraumatic stress disorder and depression. With treatment her mood improved and her trauma subsided. About two years later, on 14 October 05, she returned to the writer in a private capacity seeking treatment for depression following a relapse. She had been placed on medication by her GP but she realised that this made her aggressive and restless, and 279 also robbed her mind of the clarity she needed to resolve her issues and set directions in her life. Dee had an inner strength of character and was determined to forge a satisfying life for herself and regain her children. She wanted help to lift her depression so that she could make the appropriate life decisions. Dee gladly accepted the opportunity to pursue treatment through the intervention. She reasoned that undertaking the Internet course would enable her to blend treatment with her life in a way that did not interfere with her work or study. Having the writer available for live sessions was seen as a safeguard if she found difficulty in applying the concepts to her situation. She did not envisage any difficulties because she was familiar with CST. Dee's initial SOl and mood monitor scores were both 26 indicating moderate depression. Her first Goldberg score, reported on 19 October 05, was 46 and denoted moderate depression. The mood monitor average was 4.6, ranging from 4 in the mornings and evenings to 5.7 at midday. This reflected her generally better mood when she was at work, when her personal problems would largely recede from her consciousness. In the mornings and in the evenings at home she would have to confront the stark reality of loneliness without her children. Her inner strength and will to succeed was demonstrated in her responses to the exercise on looking at things differently (Epictetus), forwarded on 29 October 05: Write your examples below in a few words of looking at things in different ways: 1. Example 1. the future is what counts no matter how bad the past has been. Therefore don't dwell in the past 2. Example 2. being depression was bad but this motivated me to learn ways to manage it 280 3. Example 3. car accidents cause premiums to go up but garages gain their living from them 4. Example 4. there is no problem that can't be solved She began to make good progress, as indicated in her response to the assignment on the CST model, which was received on 19 November 05: (1) Think of the last time you felt really down. I was told by the doctor I might have breast cancer (2) Can you recall some ofyour automatic thoughts? Catastrophic, probable death (3) Can you recall some of your behaviour (what you said and what you did)? Was all over the place (4) Now, with 20-20 hindsight, were our automatic thoughts realistic or slanted negatively? Negatively (5) How did they relate to what you did or didn't do, said or didn't say? I thought constantly that I would not have long to live (6) Let's focus on the last one or two days: (1) at about what time was your mood good? 2 pm today (2) what thoughts were then in your mind? That my cancer was diagnosed early and that I have an excellent chance to recover Dee completed the course in 55 days. There were no major differences in days taken to complete different modules except for the first reporting period, in which Dee took ten days to present her work because of work 281 commitments. The Goldberg score reduced steadily from 46 during the course with no apparent relapses. The mood monitor scores mirrored her improvement In the last two Goldberg administrations, in the third week in November OS, her scores were 25 and 24 respectively. During her post-course session she described that in mid November she asked her mother to arrange for the return of her children. Her mother was not willing, citing that Dee was not yet well. The problem was that her mother, a drug addict, needed the foster parent payments for her own use. Dee had seen a solicitor and was considering her options. The issue of the children and the possibility that she might not reunite her family demoralised Dee and caused a pause in her improvement. However her self-confidence returned when she resolved to take legal action if necessary. As a result her mood resumed its improvement. In her post-course session on 8 December 05 she scored 7 for the SOl and 6 for the Hamilton indicating no clinical depression. She stated that though she was a counsellor herself who used CST, she wanted to do the course because she felt she needed a set program to drive her rather than rely on her own motivation for self-treatment. Dee did not seek any sessions during the course though she appreciated their availability as insurance in case of a relapse or other impediments to progress. 'It's good they were there' she commented in the session. Now that her depression had lifted Dee sought a session after the course to discuss her thoughts about her future, particularly about her intention of regaining her children from her mother's care and hence reuniting her family. The session was held on 14 December 05. Dee presented in a positive mood though tempered by the anxiety to see her children's return. She explained that she had been going to her parents' place to visit her children once a fortnight. Her mother objected to her coming more frequently. In recent visits her children became distressed when she was ready to leave and wanted to come to Sydney with her. She felt 282 heart broken at having to leave them behind and at the same time resolute to expedite their return. Dee discussed engaging the lawyer she had seen earlier but she did not have enough money to pay for legal expenses, given that her income although small, placed her just over the threshold for legal aid. She ranged over several options including enlisting her father's support, who wanted to see the children returned to her. However he was not likely to be forceful enough with her mother in any discussion of this nature. Dee resolved that the optimal approach was for her to continue seeing her children and raising the subject of their return with her mother at every opportunity. In any case, she reasoned, the oldest child would soon be at an age where he could legally choose with whom to live. Dee was pleased with having arrived at this option and mentioned that this would not have been possible if her depression had not lifted. CST helped her hone her problem-solving skills. In Dee's three­ month follow-up by phone, on 30 March 06, the SOl score was 5 and Hamilton was 6. No clinical depression was indicated. Key factors of participant experience History: depression following trauma, antidepressants ineffective, loneliness without children, relapses Attractions to online study: In charge of own treatment, face-to-face sessions available if needed, treatment blends with life Relapse: none during course Significant component: problem-solving Behaviour change: problem-solved key issue of reuniting family (e) Eric The fifth participant, Eric, was in his mid 20s. He was of Middle East background and his parents were devoutly religious. Eric had strayed from his parents' strong cultural and religious beliefs. He drank alcohol and partied frequently with his workmates though he said he did not take illicit drugs such as heroin or marijuana. He completed Year 12 in response to extensive pressure by his parents. He wanted to go into body building as a career but his parents persuaded him to find work in 283 more traditional field. He gained a position in an electronics retail organisation and soon progressed to floor manager. His diligence was further rewarded and he was given his own store to manage. Eric however could not give up the idea of body building and proceeded to train himself at the gym practically every evening. There he met another enthusiast who introduced him to steroids. Wanting to see his body image improve as soon as possible Eric began to take large quantities of steroids. He developed muscles that were much admired by his friends and girlfriends. Symptoms of excessive steroid use including aggressiveness and quick temper also appeared. On one occasion he was served with a parking infringement notice outside his store and became upset and threatened the woman parking police officer, who was also a Middle Easterner. She reported the offence, he was charged, pleaded guilty and was remanded on bail for sentencing. His barrister referred him to the writer for a presentencing report. Eric was diagnosed with depression, which had its roots in the ever increasing conflict between himself and his parents over his lifestyle and also in a relationship which had dissolved after becoming truculent and embroiling his and his girlfriend's parents. His depression appeared to be markedly worsened after he began to take steroids. The court placed him on a bond provided he attend treatment for his condition. His GP agreed that he should receive treatment from the writer. He attended his first session on 19 October 05. Eric scored 24 for the SOl and 21 for Hamilton, indicating moderate and moderate-severe depression respectively. Eric was computer literate. He accessed the computer frequently at work to update customer databases, order stock, prepare correspondence and search the Internet. He liked the idea of taking charge of his own treatment and undertaking the course at his own time and pace but almost abandoned treatment before he commenced when he found there were homework and assessment requirements. However he realised that there was little option but to pursue treatment for his own good. The Internet course enabled him to blend his treatment with minimal disruption to his lifestyle. He had given up steroids immediately after he 284 offended though he kept up with his gym. Eric said that initially he thought that depression attacked the weak willed and that he was impervious to any psychological ill because of his superb physical fitness and dominant outlook. After a discussion with the writer he gained a better insight into his condition and he appreciated that there was no shame in being depressed. He was taken back when the writer informed him that he had treated quite a few young Middle East men and women for depression. Eric had recently met a woman of his age and background. The couple liked each other and a relationship was in the offing. Following the finalisation of his court case the relationship blossomed and a wedding followed. His mother was relieved at her son settling down into marriage. His mother-in-law had some misgivings about his capacity to keep her only daughter in the comfortable lifestyle in which she grew up in a well to do business family. The couple went to the Middle East for their honeymoon and returned about a month later. Eric was in a positive mood following the marriage. However he wanted to complete the treatment because he felt that once the novelty of the marriage was replaced by the stark reality of married life his underlying depression was likely to return. There were several indicators that this was happening, such as pressures on him by his and his wife's families to change his lifestyle, from socialising on some evenings a week with his friends to going home and being a dutiful husband. His mother-in-Iaw's domineering attitude blossomed. She would often visit the couple in the evenings to check on her daughter's well being and whether Eric was home. She would complain to him that she did not think her daughter married as well as she could have. The complaints increased in frequency and often erupted into bickering which persisted until he bade her goodnight and went to bed. His wife did not face similar criticisms from Eric's mother. Eric reasoned that his mother was grateful that someone was willing to marry him and she would overlook any perceived shortcomings. She often said the Arabic words 'Hamdulelah' or 'thank God' whenever she mentioned his marriage. 285 A major reason driving his wish to do the course was that Eric did not want to risk reoffending against the law. He reasoned that by gaining skills to prevent the onset of depression in the future he reduced the possibility of anger arising and leading to another incident and hence court again. If that ever happened, his mother-in-Iaw's criticisms would be unstoppable. His inclusion in the study would indicate the value of the intervention in preventing relapse or the onset of worse levels of depression in cases where the disorder exists in milder form and there are triggers which might intensify its manifestation. Eric began completed the first module on 22 December 05, just after he returned from his honeymoon. In contrast with the indication of moderate-severe depression in the testing on 19 October 05, he advised his initial Goldberg score was 10, signifying mild depression. The mood monitor average was 8.3 varying from 8 in the day and the evening to 9 at midday while he was at work. His Goldberg score reduced to 6 during the course signifying a change in category from mild depression to subclinical. His mood monitor scores varied between 8 and 9 though these had to be checked with him at times to ensure that the attitude of 'imperviousness to emotional hurt' did not creep back in his thinking. His scores were often adjusted to reflect worse levels of mood following debate with him because he tended to be overoptimistic. Eric progressed well with the course. He had no difficulty in understanding the material in the modules. He made four personal phone calls during which he demonstrated that he had been applying thought challenging in Widely differing situations at home and work. As a result he found himself to be much calmer and less argumentative with his mother-in-law. At the same time the effects of earlier steroid use on his irritability were waning. Eric continued with his physical workouts in the gym whilst on the course but he kept away from the steroids. One of his gains in the course was that he found relaxation to be effective, particularly progressive muscle relaxation, as his emails show: 286 (17 January 06) hey John i just finished doing relaxation part 1 the breathing exercises it was great it made me feel a lot better they are really effective well i will keep going with some of the other work today. kind regards Eric (19 January 06) Hey John just finished part 2 of the relaxation module it was great helps my muscles relax and i have lots of those it was really good cause i did it straight after i finished training at the gym it helped me relax a lot plus i just went for a walk like it said to its a nice night so it was a very nice evening stroll thanks John kind regards Eric. Every now and then during the course Eric would forget to submit mood monitor or Goldberg scores. The writer would follow up with a phone call. Eric had to be convinced at times that even though he was well he should still submit his scores in order to map out his progress on the course and also alert him to the possibility of a relapse. Eric emailed at night on 10 February 06: "hey john all done can we get together and finish up this week inshallah i will bring you sweets and halawa inshallah hope to hear from you soon inshallah" He rang on 13 February 06 to confirm that he had completed the course and found it rewarding. He took 54 days to complete all requirements. He completed the end course assessments over the phone. The SOl and the Hamilton (3 and 4 respectively) showed no clinical depression. Eric made arrangements to attend a session with the writer on anger management. He had surmised that CST was the vehicle for training in the management of anger. In the session he showed that he was at an 287 advanced stage in learning to apply the skills in situations likely to arouse his anger because of opportunities created by his mother-in-law. He wanted to gain the skills as a safeguard against his temper getting him into trouble with the law or more likely with his mother-in-law, who apparently continued to voice her concern that he was not doing enough to make her daughter happy. His own mother was voicing the opposite concern namely that his wife was not attending to his needs as she should. There had already been a few simmering arguments between the mothers and Eric wanted as much help as possible to prevent venting his anger at both of them. Equally importantly he wanted to acquire the skills as a safeguard against further offending against the law. He felt that if he offended again it would greatly please his mother-in-law and she would not hesitate in triumphantly telling her daughter and all concerned that he was not a good husband after all, like she had always been saying. During the session Eric showed a good grasp of CST skills and understood well the principles in anger management. Eric was contacted on 15 May 06 for his follow-up assessment. Eric was in a positive mood. Arguments between the mothers over the alleged failings of one or another of the newlyweds continued to occur sporadically. Eric and his wife who were getting on well, kept themselves out of the way of the maternal arguments. However there were times when he and his mother-in-law did exchange heated words. The skills he learnt during the course, particularly thought challenging, enabled him to react much less belligerently though he realised he had some way to go in applying the principle of looking at her complaints in less provocative ways. The SOl and the Hamilton scores of 2 each showed no clinical depression. Eric felt that the course had greatly benefited him. Every now and then he would access the site and read through some of the material. He reported that thanks to CST he had incorporated into his functioning the Middle East philosophy of 'malesh', approximately translated to 'never mind' or 'it's happened already so why get upset'. 288 Key factors of participant experience History: depression due to culture clash, relationship break up, worsened by steroid use leading to offending Attractions to online study: in charge of own treatment, IT experience, treatment blends with life Relapse: none during course Significant component: logic challenging Behaviour change: able to manage ongoing conflict with mother-in-law without aggression. (f) Fred The sixth participant, codenamed Fred, was in his mid 30s. He arrived on a visitor's visa about eight years ago from Iran to see his brother. He was a Christian and had suffered frequent persecution from the government and the wider community. He trained as a photographer and worked in this field whenever the opportunity arose. When he arrived in Sydney he found the freedom that he wanted and could not have in Iran. He began the lengthy and expensive procedure of applying for resident status in Australia and experienced a number of rejections at different levels. He engaged an immigration law specialist who was preparing an appeal directly to the minister. The fear of being forced to return to Iran where he would be facing lengthy imprisonment or worse for having falsely gained a passport on the pretext of a short visit to his brother was constantly on his mind. The guilt he felt over being a burden to his brother and family for the last few years, his loneliness and feelings of being an alien in a society that may reject him led him to depression. His solicitor proposed to him to seek treatment from the writer and his GP endorsed the proposal. Fred attended his first session on 15 December 05. He presented in a depressed and anxious mood. His level of English was sufficient for him to converse freely as well as read and understand written instructions. He was delighted to have the opportunity to participate in the intervention. The concept of pursuing his own treatment through the Internet appealed 289 to him. He did not have a computer where he was staying but had some knowledge of using the Internet and looked at the intervention as an opportunity of improving his online skills. He arranged that he would come to the writer's premises frequently throughout the week and undertake the course on the computer in the reception office. Instead of emailing his responses he would write them on paper or save them on a directory in the computer. The writer would access them and respond accordingly. Fred was briefed on the Internet course and quickly developed the necessary access skills. Fred's initial SDI score of 26 and Hamilton score of 23 revealed his depression was at a moderate level. Fred began the course on 15 December 05. His first Goldberg score, reported three days later, was 34. This denoted moderate depression. The mood monitor average was 3.3 ranging from 3 in the morning and the evening, to 4 at midday. The low level of the scores was a reflection of his overriding loneliness and anxiety over his circumstances. During midday, unless he was in the writer's reception he would normally undertake some out-of-house activity such as walking in the park or doing the family shopping. These tasks tended to shield him to some extent from anxious and gloomy thoughts about his predicament. Fred was in straitened financial circumstances - he had no income of his own, government regulations did not permit him to work because he did not have residency and he had to rely on his brother, a factory process worker, for economic support. This made him feel guilty any time he spent money and he ensured that such expenditure occurred only where absolutely necessary. Living with his brother's family in the western Sydney suburbs meant that he had to travel by train to the writer's office to work through the course. He travelled off peak hours because he saved on the fares, which were over five dollars at the reduced rate. One outcome was that he would spend considerable time in the writer's reception office because he wanted to cover as much of the course as possible in each session, reducing the need to travel. At times he would stay on and surf the Internet, mainly gathering information for the 290 submission to the immigration minister on the persecution of Christians in Iran and his likely fate if he did not gain his permanent residency and was forced to return. To save him fares he and the writer agreed to hold post­ course treatment sessions if needed and evaluation sessions over the phone. Apart from the introductory session Fred did not need additional treatment sessions. Fred's progress was steady. He worked consistently through the course. He would devote considerable time to the exercises and reading referred sites for enrichment material. He came to the reception office several days every week except for the Christmas - New Year break. The fruits of his labour can be seen in the reduction of Goldberg scores. By the end of the course 36 days later, on 20 January 06, Fred's Goldberg score reduced from 34 to 12, signifying mild depression. His mood monitor showed parallel improvement, from an average of 3.3 to between 7 and 8. Given that there was no abatement in the pressures confronting him and the likelihood of a forced return to Iran was ever present, the result was accepted by Fred and the writer as the best possible under the circumstances. His changed outlook can be gauged from his comment to the writer at the end of the course: very good course. Feeling much better. Nothing changed but if Immigration says no I will look for another answer and not think I'm finished like before the course. The largest reduction in Goldberg scores, from 28 to 20, occurred between the second and the third administration. Fred had completed the first six modules (Epictetus and stress). In a brief discussion on 22 December 05 he said that in the previous week he found that he could reduce the distress inherent in his situation by thinking differently about it - for example he no longer felt as anxious over the threatening deportation. He reasoned that he had done all he could by hiring an immigration lawyer and providing all the information required. His research into the plight of Christians in Iran had been embodied in a 291 paper accompanying his application for residency. In this way he maximised his chances for a favourable result. If the result was negative he would worry about it then. He realised the result would be the same irrespective of how much distress he felt. Christmas was a difficult time for Fred. He joined the festivities with his brother's family and friends but his pleasure was offset to some extent by the fear of deportation. He attended a party with his brother's family. In the party his loneliness was starkly portrayed - all the other men were present with their wives and children. He was alone. Fred was contacted on 20 April 06 for his post three-month follow up assessment. He was in a positive mood and glad to hear from the writer. Fred's Internet research revealed that Canada had a more liberal attitude towards Christian refugees from Iran. His brother in Canada confirmed Fred's research. Fred had not heard about his application but in the event of a refusal he asked his brother who was permanently living in Canada for a sponsorship to stay with him and help with a residency application. His brother readily agreed and this lifted a weight of his shoulders. Fred credited the course for helping him look at his predicament as a problem to be solved rather than as a possible death sentence because of a forced return to Iran. He considered that looking at things differently was his daily weapon against a return to depression. Fred's guilt feelings about being supported by his brother ameliorated to a marked extent because he undertook a large part of the housework which his sister-in-law could no longer cope with because of her pregnancy. Fred undertook shopping, cooking, washing and housekeeping generally as well as walk the children to and from school. He was gratified to be of assistance to his brother and family. In this way he could repay their kindness notwithstanding the obligation that his brother's family felt towards Fred to support him. He would find time during the day to go to the local library and access the Internet, maintaining an interest he developed whilst on the course. He had filled his life with positive 292 activities within the limitations of the reality facing him. As would be expected his SOl score of 5 and Hamilton score of 5 showed no clinical depression. Key factors of participant experience History: depression due to possible forced return to Iran with dire consequences and loneliness Attractions to online study: pursuit of own treatment through the Internet, face-to-face sessions available if needed, treatment blends with life Relapse: none during course Significant component: Epictetus Behaviour change: saw his predicament in a different light and decided to problem-solve. (viii) Non completers (a) Glenda The first of three non completers was Glenda. She was in her late 20s and worked as a communications professional in a large organisation. She had recently entered into a relationship to which she brought her four-year old daughter from her former marriage. Her partner was also a professional in a similar industry. They were renting an apartment close to the city. Glenda and her partner were experiencing difficulties making their relationship work. She felt that her partner was relying too much on her for the day-to-day home chores. Her mother lived close by and would pick up Glenda's daughter from school and take the child to her place. Glenda would pick up her daughter from her mother's place after she finished work and take her home. Glenda would do the shopping on the way home and then prepare the evening meal. Her partner would arrive late every evening from work and was too tired to assist in the evening's household chores. Glenda would read to her child and put her to bed. She would then go to bed though at times she had some work-related tasks to do on the computer. When she finally went to bed on most 293 occasions her partner was asleep. Glenda needed to share closeness with her partner but he was either too tired or too stressed to satisfy her needs. There was some respite on the weekend from the workweek pressures and the couple would take the child to the park or to some outing for relaxation. At times the couple went out and relied on Glenda's mother for babysitting. Glenda began to resent her partner's apparent unwillingness to share household chores or to help with the child. She felt she was being punished for bringing another man's child into the relationship. There was also some tension between the couple and the child's natural father. He often visited them and created problems such as complaining that his daughter was not being cared for well enough. Work pressures, tensions with her partner, her child's growing needs and the intrusiveness of her former husband into her present relationship were stressors that were building up for Glenda. The stressors led to depression. Glenda found the writer through the Australian Psychological Society's referral service and made an appointment with the writer. Glenda attended the introductory session on 24 October 05. She presented in an anxious and depressed mood though with some determination to manage her distress and continue with her relationship. She was briefed on the intervention and readily accepted. She was attracted to the concept of the Internet course because she could plan her treatment around her busy life. Going to sessions would have meant sacrificing time devoted to her daughter from an earlier relationship and her current partner. This was a cost she would find difficulty in meeting. Glenda scored 20 on the BDI, the lowest score at the moderate depression level. Her score on the Hamilton was 17, the highest score on the mild-moderate category. On 28 October 05 she forwarded a Goldberg score of 26, just within the mild to moderate category. Her mood monitor average was 6.2, rising steadily from 5.7 in the morning, to 6.3 at midday and ending the day at 6.7. The pattern was largely due to 294 the morning rush to wake, feed and dress her child while she also readied breakfast for her and her partner, and take the child to chi/dcare on her way to work. At midday she was busy with work which she found challenging and made her happy. In the evenings, particularly after the end of the evening chores, she had an opportunity to relax with her partner at least on some nights. The subsequent rapidity in improvement is highlighted by one of her responses to the assignment on looking at things differently, submitted on 27 October 05: This is an instance that is happening now. Pete's work keeps ringing him for support most nights at the moment - it's a high point in the project and most times they call being the production of the newspapers seems to be through our dinners. It happened even while mum was here. Before I would have been very annoyed - but I have let it pass and it hasn't really bothered me. However last night he told me that he will have to work on Sunday night - I was less than impressed as he had forgotten that we have the wedding to go to. Today he emailed me asking what time the wedding is and what time the reception is so that he can support in between via laptop. Again I was less than impressed. And I let him know - but not like I used to - instead I said yes I was annoyed because I had been looking forward to that evening of dressing up and going to a great big lavish wedding with friends and seeing again people I hadn't seen for a long time and being with Pete for a great night out at a beautiful wedding - but I said that it was not going to spoil our night. When I got home he was teary because he had been fighting with his manager again about the work load (this manager was his long time friend but has gone sour over the last few months). I want to look at this positively for him and I. The day will be great. We can still dress up and go to the wedding. He can do his work in between if he things are a problem at work and they need his support - while he is doing that - I can socialize as I like doing - 295 Pete is shy and I am outgoing - so that is fine. And then we can go to the reception and have a great time seeing a good friend get married and spend a night with Pete doing something that you don't get to do often. In a telephone call three weeks later Glenda advised that she had completed the course. She had not forwarded her scores or other requirements because she felt she gained enough knowledge to resolve her depression. She and her partner worked through some of the modules together and in the previous Sunday (13 November OS) they sat down and resolved some of their more pressing issues such as sharing the housework more equitably and reassuring each other of their mutual love and support. Glenda considered that the causes underlying her depression had been largely addressed. Her distress had abated and she expressed her satisfaction at having the course available on the Internet case she ever needed to address a relapse. Key factors of participant experience History: depression due to family discord involving her current partner and child from a previous marriage Attractions to online study: treatment blends with life situation and not having to devote time away from her family Relapse: none during time on course Significant component: problem-solving Behaviour change: Negotiated changes with her partner, which resolved her depression. (b) Harry The second non completer, Harry, was in his mid 50s. He had completed a long-term career in the armed forces which apart from being challenging and demanding, left him with a legacy of negative experiences. The experiences were often triggered in his mind and made him depressed and anxious because they came close to claiming some of his mates' lives. Harry had difficulties in returning to civilian life and 296 living in suburbia. He made several attempts to gain work, spurred by the need to boost his self-esteem through having something Worthwhile to contribute outside of the armed forces. Though he was comfortable financially he felt that additional income would make his and his wife's lives a little better. Initially he found that his skills of working effectively as long as he could rely on the support of an authoritarian structure were not particularly useful in civilian environments. These and other adjustment challenges brought him difficulties at home and led to depression. He sought treatment from his GP and was placed on antidepressants. They succeeded in suppressing his mood lability but did not help him resolve the issues confronting him on return to civilian life. The GP referred him to the writer for treatment. Harry attended his first session on 29 September 05. He readily established a working relationship with the writer once he learnt that the writer was an ex-serviceman. Harry's wife accompanied him to the sessions. She was very supportive of her husband and the relationship with the writer. Harry was a recent but rapid learner of the Internet. He had acquired high performance computing equipment. His natural liking for a technical challenge enabled him to achieve a high level of expertise in working with information technology. Harry felt a little reticent in undertaking the depression Internet course on his own with email help and the occasional remedial session. He opted for weekly sessions in parallel with undertaking the program. His armed forces career made him feel more comfortable following a set structure. Harry's SOl score was 27 (moderately depressed). The Hamilton score of 36 placed Harry at the moderately-severe category. He readily admitted he was tearful much of the day and his wife confirmed his downward mood. His first mood monitor average was 4.3 and showed no variation throughout the day. His first Goldberg score was 62 denoting severe depression. Harry appeared to be generalising his behaviour from a confined period of time in depressed mood to practically the whole of the day. This became evident when he was advised to 'average out' his 297 answers on the Goldberg over a fortnight and not just on occasions when he felt particularly sad. Harry completed the first four modules and attended his fifth and last session on 20 November 05. He kept in touch after that with phone calls and emails. On his last module he reported a mood monitor average of 5.9 with a peak in the evenings of 6.7 denoting that he was able to break the depression barrier at least for part of the day. His Goldberg had reduced to 45 placing his depression in the moderately severe grouping. Harry advised that he had read the remaining modules. He felt that he gained enough knowledge and wanted to put it into good use to lift his depression. He challenged negative thoughts supporting his nemesis that he could not be gainfully employed in civilian life. He realised that he was catastrophising unnecessarily, without any evidence and that there were many former service acquaintances who were working productively in new careers. He resolved that his approach should be to intensify efforts to find work rather than let hopelessness overcome him. He reflected on his skills, searched job sites on the Internet and visited firms he thought might be interested in his particular skills. He managed to gain work in an industry which valued and drew on his armed forces skills. He worked as a contractor and hence enjoyed a measure of independence. He did succeed in obtaining a number of contracts for his services which would keep him occupied for the next two to three years. His self-esteem arose now that he felt that he could use his skills in the civilian work world. His email on 26 February 06 indicated that his depression had abated: Hi John, Sorry for not getting back to you before this but, (you know there's always a but) I have been very busy, (an understatement) with my new position with XXX Training Services as the Security Training Manager. 298 There isn't enough paper to write on to tell you what well have been up to so when I can make an appointment with you again I'll tell you all about it. I have to go for now, catch you later. Regards, Harry Key factors of participant experience History: depression due to adjustment to civilian life after a career in the defence forces Attractions to online study: technical challenge in pursuing own treatment through the Internet, face-to-face sessions in parallel, treatment blends with life situation Relapse: none during time on course Significant component: problem-solving Behaviour change: found satisfying work, which lifted his depression (c) lisa The third non completer, lisa, was in her mid thirties. She had a difficult life. Her father left the family shortly after her birth and she was brought up initially by her maternal grandparents. Her mother remarried but the stepfather took little interest in his wife's children. In the mean time her mother pursued a number of extramarital affairs and the marriage eventually broke up. lisa went to live with an older cousin initially and she was then farmed out to other relatives. She changed schools several times because of her frequent moves between her mother and relatives. She did not manage to attend school beyond Year 10. She married at the age of 18 to find a sense of stability in her life and had four sons in the next six years. Her marriage destabilised as both partners pursued extramarital affairs and finally broke up. While she was trying to pick up her life she was raped by a group of men in her own home, who had been working in a nearby building site. The police were unable to arrest the 299 perpetrators even though she had a message on her mobile by one of them. The incident caused her considerable distress. She received counselling for posttraumatic stress disorder. As her trauma symptoms receded depression set in, fed by her feelings of Worthlessness and self­ loathing. She could no longer look after her teenage children so they went to live with her sister temporarily. Over the next two years lisa found her way back into her life and reunited her family. She completed TAFE training and gained work which gave her a reasonable income. Her depression however continued to distress her and would arise whenever she was reminded of her sexual assault and her childhood abandonment. She came to the attention of the authorities over a fraud charge and her solicitor advised her to see the writer for a presentencing report. The writer diagnosed depression and remnants of trauma symptoms. Her solicitor recommended that she attend for treatment and her GP agreed. lisa attended on 27 October 05. She was attracted to the Internet course because she lived in a country town which was two hours away from Sydney. She was comfortable with the writer because she had already established a professional relationship with him during the legal assessment. The option of attending sessions as required appealed to her. However she felt that it was unlikely that she would be taking advantage of their availability, preferring email contact if she had the need to do so. Moreover she had formed a relationship with a man and they planned a wedding in the next few weeks. lisa scored 26 on the SDI which placed her at the high end of the moderate category and 28 on the Hamilton, which was within the moderate-severe grouping. When she returned home on the same day as the assessment lisa proceeded with the course. She completed the first two modules. Her Goldberg score was 72 signifying severe depression. Her mood monitor average ranged between 2.2 and 2.7, the lowest of all participants. In her accompanying email she commented on her Goldberg score: 300 I thought it would have been less than that. I am having trouble with this module as I cant concentrate long enough to get through the tasks I have really tried to do it. lisa did not complete any more modules. Following an email on 20 November 05 which the writer sent to enquire into her wellbeing and progress, she rang on 3 December 05 to say that her mood had lifted considerably following her marriage. She was very happy, her children were pleased with her new husband and her life was coming together for the first time ever. She felt as if a black cloud had lifted from her and she was able to pursue her life without depression. She had downloaded the Internet course into her computer so that she could study it whenever she needed help. Key factors of participant experience History: depression due to earlier trauma and life difficulties since childhood. Attractions to online study: no travel hence no drain on time; availability of face-to-face sessions if needed. Relapse: none during time on course Significant component: none advised Behaviour change: changed life circumstances 301