Men’s Health Week

15–19 June 2020

During this week we focus on men’s mental health and what we can do collectively across the UQ community to help. Accepting support, overcoming stigma and changing the idea that men need to be tough and keep going at the cost of their health is something as a society we want to overcome.

UQ Men’s Mental Health Week Ambassador, Professor Stuart Carney, Deputy Executive Dean, Faculty of Medicine, introduces us to men’s mental health – an important topic that relates not only to men but everyone in the UQ community.

Read Stuart's blog on Shaping conversations about men's mental health

Event: Live mental health Q&A

Thursday 18 June 2020, 12–1pm

Are there questions about mental health and wellbeing you’ve always wanted to ask? Does exercise and diet really help? Are you concerned about a friend or family member? Do you need help finding support?

Celebrate Men’s Health Week by joining a live online mental health Q&A session. Hear the discussion and ask questions of our panel of mental health doctors and experts: A/Professor Dan Siskind, Dr David Nguyen, and Dr Peter McCardle. Register to attend via this week’s UQ update. You can also post your questions beforehand on the day.

Podcasts

We are grateful to our experts for sharing their own personal insights into men’s mental health. We hope you enjoy listening to their stories and valuable tips for your own mental wellbeing and for supporting others.

Men’s mental health: let’s start talking!

Dr David Nguyen is a psychiatrist who works in a local private practice. He talks with Prof Stuart Carney about men’s mental health and his experiences around why men are sometimes reluctant to let others know when they are not coping. He shares some insights that will help us all to reach out, and start talking.

Transcript – Men’s mental health: let’s start talking!

STUART CARNEY: Welcome to the UQ Mind Matter podcast. My name is Stuart Carney and I'm the Deputy Executive Dean at UQ's Faculty of Medicine. In this podcast series, we aim to change how men of all ages and demographics think, and talk, about mental health. On average, one in eight men will experience depression, and one in five will experience anxiety at some stages of their lives, while six out of eight suicides in Australia involve men.

In this episode, we are shining light on the mental health of men, including those who identify as men, and we'll be chatting with Dr David Nguyen, a trained psychiatrist with a practice in Toowong that provides support to a number of our staff and students at UQ.

Due to the relatively high incidence of mental ill-health in our community, it's likely that many of you listening will have had your own experience, or know of other's experiences with mental ill-health through a family member, friend, or even a colleague.

So, Dr David Nguyen, I'm sure our discussion today will resonate with many of our listeners from all across the UQ staff community. David, thank you for joining us today.

DAVID NGUYEN: Stuart, thanks for having me.

STUART: David, what attracted you to mental health, and men's mental health in particular?

DAVID: Interesting question. In terms of myself - my journey into psychiatry and mental health was purely by accident. It was actually through experience through medical school, and together with the internship, where I managed to get exposed to a few mental health terms. The work in mental health intrigued me, particularly because you managed to sort of be involved in people's lives. In particular, that they gave you the ability-- To give you some level of trust in order to actually provide you with a lot of information about their personal lives, and then you're able to understand bits and pieces about themselves in the background, as well as how they develop their ways of thinking. And in particular, I think it allowed me to sort of understand a bit more about myself as well, at the same time. In terms of, I guess, men's mental health - from a personal perspective, I'm a father. And so, a lot of the issues that do arise in relation to people, and in particular men in terms of mental health, have been transitions in life. And for me, the transition into fatherhood has been quite a challenging perspective. I think it has its ups and downs, as you would understand. In particular, you need that support in order to help you. The other aspect as well, is the nature of my work does involve a lot of veterans. I would say about thirty to forty percent of my caseload involves people from a military background, and for me, I'll never experience what the veterans that I see experience, but being able to help them and support them through stages of life and transitions back to civilian life has been very confronting, but also a very important perspective for me to understand as well.

So that's, I guess, that's where it leads on to my interest in men's mental health, really.

STUART: Thank you, and as you say, you have a lot to draw upon from your personal experience but also your professional development.

DAVID: Yes, definitely.

STUART: But David, everyone gets a bit stressed and that's normal right? Isn't it?

DAVID: Good question. Look, stress its itself - I'll provide a definition, I guess. From my perspective, stress is sort of defined as a feeling of being under pressure and overwhelmed. Stress itself, when managed quite well, can actually be quite a positive thing, in that it can actually play a vital role in driving us to achieve what we want to achieve in goals. However, the issues that do arise from a lot of stress is when the challenge to meet those expectations versus the coping skills are being pushed to a limit. And as such, for a lot of people, sometimes a level of stress can be quite difficult to manage, and essentially, this leads on to discomfort. Probably all the listeners are aware, stress can develop over time in relation to multiple, sort of, spheres. So, predominately we talk about the work sphere, but there's also relationships, financial stress, and particularly, I think at the moment with what's going on with COVID - that's created a level of stress in the home environment.

In terms of normal versus abnormal, I think it's when it affects your life and becomes quite pervasive. Whether it affects your outlook of life, as well as your ability to actually manage with what's going on for yourself, and it can actually be quite difficult to manage. And for a lot of people - the patients that I do see - they cope with those emotions in relatively different ways, from an abnormal to a normal type of approach. So, I have a group of patients which I manage in terms of drug and alcohol, and a lot of patients manage their stress in that way. Others work long hours. Others take more time away from home. Others get aggressive and get quite reactive. And so I think it's important to be aware of those triggers and cues, and be able to manage that stress.

STUART: Thank you. So if I understood correctly, stress affects people in different ways...

DAVID: Correct, yes. That's correct.

STUART: ..and what might be at a normal stressor for some, may have a significant impact on others.

DAVID: Yes, that's right, yes.

STUART: So, men can be reluctant to talk about how they're feeling, or admit they're not coping. What are your experiences around this?

DAVID: Look, I think men tend to be reticent to talk about their mental health, or to talk about stress. I think that there's a layer of assumptions that have been placed on men in society, where men, in general, are meant to be invulnerable, self-reliant, and stoic. And as a result, there is that pressure internally in order to push things away. Again, they're also reluctant to seek professionals and, in light of that, at the same time - this is also because I mentioned before about my work with veterans - it's much more pronounced, because there are concerns about the implications that it has in terms of their career. Also there are-- With respect to understanding emotions, men or people in general have some form of difficulty in expressing those emotions. In particular, they can't explain how they feel and as a result, it leads to frustrations in being able to seek that help and support. As a result, when they're unable to actually express frustrations in relation to their lives, it leads on to fraying of relationships.

And I guess the last thing I like to add - in terms of expressing those emotions, there's a degree that being able to be vulnerable is quite difficult, and as a result I think there is that reluctance to seek that support in mental health, as a result of that.

STUART: So, that reluctance to seek help - does that play a part in sort of stress and mental health issues turning into something more serious?

DAVID: Oh definitely, Stuart. In light of the avoidance of expressing those emotions, or the restriction of those expressions, it can often lead to isolation and perpetuate that problem. Furthermore, it also leads on to less support being provided and being available. It can also lead to health issues as well. What we do know, is there is an interesting dynamic between the mind and the body, as well. So carrying a lot of tension can lead on to development of illnesses specifically related to escalation of sympathetic drives and whatnot. In particular, we worry about people experiencing cardiovascular issues in relation to that. Further to it, it can lead to conflict within relationships and also can develop psychological conditions that obviously, I help to treat, especially with respect to depression and anxiety. And obviously, as an extension of that depression, can lead onto negative thoughts and negative outcomes as well, which can be what we aim to avoid here.

STUART: Speaking up about this, talking to trusted family, friends, colleagues, health professionals - what role does that play in improving mental health?

DAVID: Look, I think it's an important role to have people involved in this. If you remember Maslow's hierarchy of needs - relationships and connections are basic, sort of, core needs that we are meant to have. And it's extremely vital in situations when people are dealing with emotional issues. I think it's probably one of the big things that are the most important things in terms of management - being able to actually share and discuss thoughts and allows the opening of perspectives and the awareness of other people's opinions, in terms of treating and helping with mental health.

Most people would regard that running away from these issues would solve it, but it often makes it worse in the long run if we're not able to express it. And there's obviously a lot of support that can be provided from friends or family, and particularly health professionals, in light of this. I think it's also come to the forefront in terms of popular culture - you've got celebrities voicing out about mental health issues and also athletes talking about it, and advocacy in relation to that. So, I think it is a really important step to involve other people with respect to it.

STUART: That, sort of, sense of connectedness through the relationships - through those conversations, as you say - really important, and something we're very much committed to fostering and supporting here at UQ.

Now, you're a psychiatrist...

DAVID: Yes

STUART: What's it like coming to see you? I mean psychiatry gets a bit of a bad rep in some of the movies.

DAVID: [laughs] That's quite fair. I always say - always preface it to my patients - that it's not the same as in movies. The way I sort of see it, is that there are going to be layers of that anxiety when you meet someone new, that doesn't know you, and you're about to talk about questions that are quite difficult to actually approach, and difficult to answer. On the flipside, I always say to my patients too, that I feel anxious on the other end. Because I want to be involved, in terms of supporting them in their recovery. And I mean, a big thing with seeing a psychiatrist is the layer that-- There is that acknowledgment that there are going to be a lot of questions, and there are going to be difficulties in answering them. Essentially for me, it's about forming a layer of trust with the patient. So for me, it's about understanding what the patient thinks about, understanding that there are going to be difficulties over time - in particular about expressing their emotions - and the big thing is here, that I'm a psychiatrist that likes to focus on goals for the patient. What are their expectations out of treatment? Whether that may involve medications, whether that may involve perspectives, whether that may involve extra support externally. So I think, for me, that's what I like to think that all of us health professionals can do, and over time develop that form of rapport and trust, as well.

STUART: So, meeting people where they're at.

DAVID: Yes.

STUART: So, if we don't have a trusted mental health professional relationship we can turn to, UQ has a variety of mental health and wellbeing-related support services available to staff. These include the Employee Assistance Program which is free and confidential, which offers counselling and wellbeing service, the UQ psychology clinic, UQ Healthcare and medical service as well. Or you can reach out to our fabulous UQ mental health champions.

If you have any questions on mental health, the support services are available here at UQ. Further info, and all these services, can be found on the UQ internet pages.

But David, before we sign off, do you have any final insights you would like to leave our listeners with today?

DAVID: I think the big thing is, we should not feel shame or guilt in relation to experiencing our emotions, and we can find ways of understanding this to help with navigating our experiences of life. I think the biggest message that I give to people, is that we do have an obligation to check in with ourselves daily and weekly. And it's important to try and support each other and look out for each other, and provide that support for each other. So hopefully, this helps along that way.

STUART: Thank you. Very helpful, David.

That brings us to the end of our first UQ Mind Matters podcast. If you want to learn more about any topics covered in this episode, visit our website, where you can also access all UQ's mental health support services. If you've been affected by any of the topics covered in this episode, we also encourage you to reach out for support. As a staff member, you can access support from Benestar, the University's Employee Assistance Program on 1300 360 364. Alternatively, you can contact Lifeline on 13 11 14, or BeyondBlue on 1300 22 46 36. Each of these services are available for support 24 hours a day, seven days a week.

Hugo's story: young but not invincible

Hugo Toovey is a Movember Ambassador and talks with our staff Workplace Psychologist, Dr Kate Smith. Hugo shares his own story of cancer battles, associated mental health challenges and why youth, men and people of all ages, are not invincible. He discusses the importance of taking time to look after our mental health, which is just as important as our physical health.

Transcript – Hugo's story: young but not invincible

STUART CARNEY: Welcome to the UQ Mind Matters podcast. My name is Stuart Carney, and I'm the Medical Dean at the UQ Faculty of Medicine. In this podcast series, we aim to change how our community thinks and talks about men's mental health. On average, one in eight men will experience depression, and one in five will experience anxiety at some stage of their lives. While six out of eight, of every suicide in Australia, involves a man. In this episode, we are focusing on the issues relating to young men and chat with Movember ambassador Hugo Toovey. Hugo will share some of his own experiences with mental health struggles in conversation with UQ’s workplace psychologist, Kate Smith.

KATE SMITH: Hi Hugo, thanks so much for giving us your time today. What would be great, would be to learn a little bit about yourself and also what led you to being an ambassador for Movember.

HUGO TOOVEY: Hi Kate, no worries at all. Thanks very much for having me and it's great to chat with you today. And yeah, absolutely. So, my name is Hugo and I'm currently a captain in the Australian Army. I'm only 28 years of age and, I suppose, my health journey started about seven years ago when I was only 21, when I was first diagnosed with testicular cancer. And then, sort of throughout my journey, and various treatment through that, I was unfortunately then, diagnosed with bowel cancer about five years later, which was completely separate to the testicular cancer, and then throughout that whole journey I suppose also learned to realise the importance of my mental health. And I did struggle a lot with depression and anxiety, which originally I kind of put to the side, and focused on my physical health. But later realised the importance of also looking after my mental health. So, basically from where I'm sitting today, it's been about a seven year journey, with a couple bouts of cancer and ongoing battles with my mental health. But look, I'm here today - albeit missing a few organs - but that's alright, I'm doing pretty well at the moment. So, I suppose that's what got me into the whole journey with realising that something like what I've gone through affects people of all ages, and then that connected me with Movember, who do fantastic work for men's health and namely testicular cancer, and also mental health. Mental illness and suicide prevention, which is obviously very close to my heart, and my journey. So, I suppose that's what initially got me involved in Movember, as a mo bro raising money for them, and then eventually down the track, also becoming a community ambassador and helping out with some fundraising events, and getting out there and raising awareness for a good cause.

KATE: You've definitely gone through a real difficult journey with your health and it's understandable that that then impacted your mental health and your mood. How did you know that you needed to get support? Because you were talking about that moment where you had sort of pushed your mental health to the side and then all of a sudden you were like, "Actually, that's something that I need to look at".

HUGO: Yeah look, it's an interesting question Kate, because when I was going through these, sort of, battles with cancer, and I had a lot going on you know. I was in hospital for long periods of time, and then I underwent chemotherapy and had lots of different treatment and I suppose-- I think that was my priority, to really focus on my physical health. But throughout all of that I was struggling a lot with my mental health, but I was quite young and naive, and I didn't actually know too much about, I guess, the intricacies surrounding mental illness and depression and those types of things. I've never experienced it. I've had very fortunate upbringing and very fortunate life up until to that point. So, it was the first time in my life where I'd really experienced that. So, to be honest with you, initially I kept it hidden and I was very closed and I didn't actually talk about it. And that's why looking back on that, I really regret doing that, because I felt, when I was in hospital and when I was with my family and my friends, I always had to have that brave smile and that sort of optimism. So, that was kind of the persona that I had. But to be honest with you, a lot of that - although I did try and be optimistic - I did struggle as well, so quite often when I found myself by myself, I'd break down in tears. And I realised I was actually really, really struggling. I was vulnerable. I was scared. I didn't know what was going to happen. And I think the more I kept that closed off and I didn't, sort of, talk about my emotions and my feelings and I didn't seek that help, the worse it got until I realised that I had to do something about it. And I eventually did reach out to my partner and told her I was struggling and, sort of, took the first steps and eventually started getting some professional medical help, and then I was more or less diagnosed with depression. For me, that was a big shock, but it made a lot of sense. It was a huge relief almost, that I had kind of opened up and felt like, you know, it was nothing to be ashamed of. I was doing so much to look after my physical health and now I was doing the right things to look after my mental health.

KATE: Yeah, some of the things that you're saying really resonate with me. I think sometimes, especially when we're struggling, we tend to go to into survival mode, where we almost try to shut down and make our world quite small to protect ourselves. It seems like the stepping stone for you, was actually reaching out to your partner and talking to them about how you were going. You said that you had engaged in some medical support - who did you see? How did that process of getting support for your mental health start?

HUGO: So look, fortunately I'm in the army, and the army are very-- They've always looked after me, and so when I first went to my GP - my army doctor - and we were talking about how I was recovering from surgery and these types of things, and I kind of said "Look, I'm also actually-- I'm struggling a lot, you know. I'm just not myself. I'm having lots of down days and I just-- I'm not sure", and he said "Okay, it might be worth seeing a psychologist. You know, you've been through a lot". So I did see a psychologist, and it was one of those things that it was kind of-- It was such a normal thing to do. But I kind of built this thing up in my head that it was this strange, taboo thing, that if you saw a psychologist it meant that I was suicidal and I was, you know, seriously depressed. But that wasn't the case at all. Yes I was struggling a lot, and yes I probably, no doubt, had bouts of depression. But I think it's important that people realize that you don't have to be at the very far right end of mental illness for you to see a psychologist. And that's what I didn't initially understand until I saw a psychologist and really kind of opened up, and then it was pretty clear that I'd been through a lot, and the reasons why I was struggling, and then we just regularly spoke, and talked about ways to improve that and promote good mental health. Which is what we eventually did. And look to be honest with you, I still have down days - my mental health is pretty fragile - but I'm still-- it's a work in progress and I'm proactive with it. I still regularly see my psychologist. And even with the limitations of COVID-19, I've still managed to speak to her via Zoom and via the phone and have regular catch ups and just to check in on me, which I think is fantastic. After every single appointment, I walk away with a smile on my face and always feeling so much better. Just to talk to her about it.

KATE: And I think one of the things that you said - that I think is so common and in my experience as a psychologist - is that people think they have to wait until it's really, really impacting their lives. And obviously that's-- We want people to engage in support earlier. Why do you think that is hard for people - particularly young men?

HUGO: I think it's because-- Unfortunately I still think there is a bit of a stigma surrounding mental illness and seeing a psychologist, and I think the sooner we will start normalising the conversation surrounding mental health, the better it will be. Quite often, if you catch up with your mates, we all seem to talk about - if you play footy, how you're feeling with your injuries, and you know, you're going off to the physio and going off to the chiropractor and getting a deep tissue massage, and these types of things are just part of normal conversations, especially amongst young men. But as soon as you say "Look, I've actually-- I don't know what it is, but I've just been struggling a lot. Been having lots of down days. I haven't been sleeping much" and, you know, all these things start to come out - it's one of those things that, I feel like people struggle to know what the right thing is to say when they're approached with that sort of conversation. And then, it's changing that stigma to go "Okay, no worries mate", and for someone to realise that there's no shame in seeking help and say "Oh yep, I saw a psychologist last week because I've actually been struggling a lot" and "I feel so much better after seeing see my psychologist". So, I think there lies a pretty big issue - it's just normalising that conversation. And look, being in the Army, I know exactly what it's like. Sometimes there is that macho mentality, where we almost think that there's some sort of shame around being vulnerable and sharing your emotions and putting your hand up to say "Yeah look, I'm struggling". Which I just think is so wrong, and I think that the sooner we start changing that - and we can all help by doing it and create that ripple effect - then it will just be part of everyday conversation.

"Steve-o, how're you going mate? How did your psychologist appointment go last week?", "Yeah, it was really good actually, and I'm looking for a friend of mine - do you have any recommendations for a good psychologist? Or a good mental health nurse?".

These types of conversations, I think, is where we got to head, and I think it's improving. It is improving. But I still think we've got a way to go yet.

KATE: Yeah, and what you're saying that I think is important to reflect on - it's about those day-to-day conversations with the people around us. Because often, it's those people around us that see that we're struggling but also who we start talking to or alluding to difficulties in the first place. So, I think having ideas about how to respond. How to talk about your own experience. But also, how to respond to someone you're worried about and their experience is really important. What would your tips be about-- How do we best approach a young man if someone was worried about them?

HUGO: Yeah look, honestly - I think the best place to start is by having a conversation. Movember recently released something called Movember Conversations, and that's all about helping you approach those difficult conversations. It's a fantastic tool and if you search through Movember, and search for Movember Conversations - it's a very interactive tool. Quite often that can be the best place to start. And look, I know from personal experience that, like I initially was saying to you, Kate, when I was quite closed and I had that, sort of-- Almost that fake smile, in many, many ways - it's a great example for other people to realise that just because your mate, or your friend, or your colleague, or your brother, your dad, might say "Look, yeah I'm fine" and say "No, everything's fine" - yes it might be, but don't always take that on face value. It's important to think, well if you've noticed any changes in their mood and their behaviour - just because they're saying they're fine doesn't always mean they're fine. I know that from personal experience, that I would always say that I was doing really well and I was completely fine, but actually through those layers, I was really struggling. So my advice for that, would just be - and from personal experience - to have the conversation and to ask them how they're going. Once again, if they're coming back not with too much-- I've experienced that as well. I've also found that if you're vulnerable yourself, and you share how you're feeling, and you let your guard down, that can often be a good starting point for your mate or whoever it is to also open up about how they're feeling. To make them realise that, "Hey mate, there's nothing wrong in sharing your emotions right now", and you know what? Quite often it's a brave thing, or a courageous thing, to be vulnerable and it's something that I'm pretty passionate about, is showing my vulnerable side. I think by doing that, you can encourage others to do the same.

KATE: Yeah, I think that what you're saying, is that it's about persistence, but also about showing that it's ok to not be ok. It's ok to be vulnerable and you're doing that through your actions as well.

HUGO: Yeah, absolutely. I think that's the biggest one. There's so many amazing resources out there, and people like yourself who are the medical experts in the field. At the same time, it can literally start at the lowest level, and it can start with you. I think by just having those conversations, and encouraging someone who is struggling to seek help - they don't have to go and book an appointment with the psychologist in the first instance. They could go online and have a--

KATE: Have a look, yeah.

HUGO: Exactly. There's so many tools and amazing resources out there to help.

KATE: And seeing a psychologist - at the end of the day, it's just a conversation. I think that's always a good thing to reflect as well. It starts with a conversation. It could start with a conversation with a friend, and then hopefully - potentially, if it's needed - go to a conversation with a health professional.

HUGO: Absolutely - and look, to touch on that as well - the biggest one I always say, is that if you flip it around, and think, "What if I was really struggling? What if I was the one that was really, really struggling?" - because I've been there. You do feel alone, in many respects, and you feel like no-one can relate to you. And quite often you get in those really dark places. It isn't great. If you flip that, and go, "What if that was me?". Would I want a family member or a mate to reach out to me and ask how I was going, and say "Mate, Hugo, no - how are you really going? How are you really going?". I would, you know. Because all of a sudden, you would realise, "Hang on a second - these people actually care about me. There are so many people that care about me".

So, I think that's the biggest one for people listening to this - if you're struggling, or you know someone's struggling - you're never alone throughout all of this.

KATE: And it's important to reach out whenever you can, and if you are concerned for someone - even if, at first they say "No, I'm fine, I'm fine" - it's about coming back to it and being persistent. Being there as a friend.

HUGO: Yeah, exactly.

KATE: Hugo, I feel like it was a really informative conversation. I feel like it's just so interesting to have heard you journey, because you've been through so much and the fact that you're able to talk so openly about it says something about the work you've done. I feel like it really shows the struggles that you've gone through are able to actually help other people hopefully get support as well and take stigma and shame away from these conversations. I really appreciate your time.

HUGO: No worries at all, Kate. Once again, thanks for having me, and I'm always happy to help a fantastic cause. I know you guys at The University of Queensland do amazing work in supporting Movember, and lots of charity and fundraising initiatives, which we all appreciate. It's amazing to see so many people supporting great causes, and at the end of the day - we can all help by continuing these conversations and hopefully changing the stigma surrounding mental health.

KATE: Thank you very much for your time.

HUGO: Thanks Kate.

STUART: That brings us to the end of another episode of UQ’s Mind Matters podcast. If you want to learn more about any topics covered in this episode, visit our website, where you can access all of UQ’s mental health support services.

If you have been affected by any of the topics covered in this episode, we also encourage to reach out for support. As a staff member you can access support from Benestar, the University’s employee assistance program, on 1300 360 364. Alternatively, you can contact Lifeline on 13 11 14 or Beyond Blue on 1300 22 46 36. Each of these services are available for support 24 hours a day, 7 days a week.

My name is Stuart Carney and on behalf of UQ, please stay safe, be kind to yourselves, and support each other.

Thanks for listening.

Resources

There are a number of reputable Australian organisations that have useful information and resources on men’s mental health including:


R U OK? Day

Thursday 10 September 2020

UQ supports R U OK? Day, a day dedicated to reminding us that connecting regularly and meaningfully with people around us can make a difference.

Asking 'are you OK?' shouldn’t be limited to just one day. Help build a safe and healthy workplace culture where people feel confident asking – and answering – this question at any time.

Hosting events

We encourage all areas across UQ to hold activities that bring staff together.

If you are planning an event, make use of the event planning and hosting resources on the R U OK official website. There are also free downloadable resources for asking 'are you OK?' and starting conversations in different environments, including at work.

Need help?

UQ students can access free confidential counselling through the Counselling Services at Student Services.

UQ staff and their family members can access free confidential counselling with UQ's Employee Assistance Programs (EAP).

Beyond Blue have designed an app, BeyondNow, which can help you develop a safety plan and stay connected with family and friends. It involves creating a structured plan that you can work through when you are experiencing suicidal thoughts, feelings, distress or crisis.