Journal articles on the topic 'Psychic trauma – Patients – Family relationships'

Neuro-endovascular therapy is regarded as one of the greatest achievements of modern medicine because of its effectiveness and low-invasiveness in the treatment of difficult neurovascular diseases. On the other side of the coin however, occasionally complications may occur which not only have a profound neurological effect, but also have a severe effect on the vital prognosis. The nightmare of a neuro-endovascular therapist is a catastrophe resulting from a preventive treatment for an asymptomatic or minimally symptomatic patient with a potentially dangerous disease. Therefore, grave psychic distress tends to occur on both sides of the patient-doctor relationship. Once severe complications occur, we have simultaneously to take care of not only the psychic trauma of a patient and/or family but also our own psychic trauma. If treatment is not appropriate, we might invite malpractice suits or end up in occupational burnout. In order to study the adaptive mechanisms that allow our continued survival in this new specialty of medicine, we administered a questionnaire survey to members of the Japanese Society of Neuro-endovascular Treatment. 51% of 300 respondents stated that they had been the targets of severe recriminations by patients and/or families as a result of complications. 284 respondents had multiple (2.5 on average) signs and symptoms of psychic trauma. Also 23% of respondents were unable to continue the clinical practice of neuro-endovascular therapy or resorted to conservative treatment. Only 7% of respondents had medical curriculum or residency program training on the psychological problems of complications. There is no systematic approach to education regarding physician grief in clinical practice. Many respondents tend to focus their attention solely on the details of failed interventional procedures and repeatedly “undo” actions and relive past events. However, the study showed that intellectualization of the tragic experiences without accepting and working through grief only adds to the physician's grief. The correlation was evaluated between the respondents' initial response to grieving and their change of attitude regarding their ability or willingness to performing the procedure after they had experienced devastating complications. It may be said that by facing the emotional truths of responsibility and grief, physicians can develop the ability to empathize with patients and their families. Mention is also made of the patient-doctor relationship, medical education, and the relationship with fellow physicians and medical lawsuits.

Šio tyrimo tikslas – nustatyti situacijos sunkumo įvertinimo ir psichologinės kančios ryšį laikui bėgant. Gauti rezultatai rodo, kad pirmą psichozę išgyvenusių pacientų artimųjų situacijos sunkumo įvertinimas ir psichologinė kančia reikšmingai pasikeičia jau po trijų mėnesių. Pirmą kartą psichoze sergančių pacientų artimųjų pradinio situacijos sunkumo įvertinimas prognostiškai reikšmingas tolesniam situacijos sunkumo įvertinimui, o psichologinės kančios iš jos pradinio įvertinimo prognozuoti negalime. Iš pradinio situacijos sunkumo įvertinimo galime prognozuoti vėlesnę psichologinę kančią.Pagrindiniai žodžiai: pirmas psichozės epizodas, artimieji, situacijos sunkumo įvertinimas, psichologinė kančia.Relatives of the First Episode Psychosis Patients: Relations between Assessment of the Situation’s Difficulty and Psychological Distress Over TimePovilaitienė I., Gailienė D., Pakalniškienė V. SummaryThe aim of the study was to assess relationships bet­ween the assessment of the situation’s difficulty and psychological distress over time by the relatives of the first episode psychosis patients.The sample of the study comprised 30 relatives (parents 63%, siblings 26%, and partners 10%) of the first episode psychosis patients. Participants of the study were interviewed during the first 10 days after the patient’s admission to the hospital, and then 3 months and 9 months after the first interview. Criteria of the participation in the study: an adult family member of a first-time hospitalized patient; the patient’s diagnosis – psychotic disorder (F20 or F30 with psychosis, ICD-10); a patient no older than 40. The study proceeded at psychiatric hospitals in Vilnius. Relatives: age M = 42.3, SD = 13.24); gender: men 37%, women 63%. Patients: age M = 24.07, SD = 4.87, gender: men 70%, women 30%. The following variables were investigated: demo­graphics, assessment of the situation’s difficulty (perceived psychological trauma subscale (Lewis, 2005)), psychological distress (Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983)). Data were analyzed by the repeated Anova and testing by the cross-lagged panel design model.The results showed that the relatives’ assessment of the situation’s difficulty and distress improved significantly during the first three months. The prognostic value of distress and the assessment of the situation’s difficulty at Time 1 were different: assessment of the situation’s difficulty overtime was predicted by assessment at Time 1, but the distress overtime was not predicted by the distress at Time 1. Cross-lagged analysis revealed that dis­tress over-time was predicted by the assessment of the situation’s difficulty at Time 1. The results of this study suggest that professionals working with families should pay more attention to diminishing relatives’ negative assessment of the situation from the beginning, because it predicts significantly the later distress.Keywords: first episode psychosis, relatives, assessment of the situation’s difficulty, psychological distress.serif;">

Total laryngectomy, as extremely mutilating surgical intervention, results in drastic changes of the style and quality of life. The trauma of laryngectomy is huge, both to patients and their environment. The most pronounced changes of the quality of life of laryngectomized patients are seen at marital, familial, professional, business and communication aspects. Malignant disease and total laryngectomy significantly reduce working capacity, producing, besides professional, the economical difficulties. Psychological implications associated with total laryngectomy are the most severe, comprehensive ones and require multidisciplinary approach. The study analyzes the frequency and distribution of factors affecting the quality of life of laryngectomized patients (sex, age, psychic status, probable history of chronic diseases, impairment of hearing and social-family environment of patients). Significant improvement of the quality of life of laryngectomized patients is achieved by systemic, planned and multidisciplinary rehabilitation of patients as well as their immediate environment. The need for the association of laryngectomized patients is stressed.

IntroductionThere is a growing interest in establishing a relationship between several mental disorders and traumatic life events in childhood and adolescence.It has been seen a high prevalence of these traumatic events when reviewing the clinical history of patients with mental illness.AimsMeasuring the prevalence of traumatic events in a sample of patients with a diagnosis of psychotic disorder.MethodologyA retrospective descriptive study was made. The sample comprised 50 patients admitted to our psychiatric inpatient unit. These patients were separated into different categories according to clinical diagnosis and demographic variables. Data was obtained through clinical interview before their hospital discharge. We tried to detect the presence or absence of real or imaginary memories of traumatic events during their childhood or adolescence.Results52% of patients had a diagnosis of paranoid schizophrenia. 64% reported a history of substance abuse in their family. 20% referred the experience of having suffered sexual abuse by a member of their family, and up to 44% of them by someone other than family. 22% reported having suffered some kind of physical abuse by their parents, and more than 70% reported having suffered some type of traumatic event in the school environment.ConclusionsThere is an important amount of traumatic events in childhood and adolescence in this sample of patients. However, concluding that such traumatic events could eventually produce severe psychiatric disorders is still quite controversial. In order to understand better the association between childhood trauma and severe mental illnesses more research is needed.

The aim of this study is to analyze how the length of time a patient spends in an Intensive Care Unit (ICU) affects close relatives, with regard to specific clinical variables of personality, family relationships and fear of death. The study group consisted of 57 relatives of seriously ill patients admitted to the ICU of “Virgen del Rocío” Rehabilitation and Trauma Hospital (Seville, Spain). The instruments applied were: a psychosocial questionnaire, clinical analysis questionnaire, family environment scale and fear of death scale. The relatives of patients admitted to ICU obtained higher scores in hypochondria, suicidal depression, agitation, anxious depression, guilt-resentment, paranoia, psychasthenia, psychological maladjustment and self-expression, and less in fear of their own death, as when compared to interviews with the same relatives 4 years later. The length of time a patient spent in the ICU influenced relatives in some clinical variables of personality, family relationships and fear of death.

AbstractBackgroundPsychosis-like experiences (PEs) are common in patients with non-psychotic disorders. Several factors predict reporting of PEs in mood disorders, including mood-associated cognitive biases, anxiety and features of borderline personality disorder (BPD). Childhood traumatic experiences (CEs), often reported by patients with BPD, are an important risk factor for mental disorders. We hypothesized that features of BPD may mediate the relationship between CEs and PEs. In this study, we investigated the relationships between self-reported PEs, CEs and features of BPD in patients with mood disorders.MethodsAs part of the Helsinki University Psychiatric Consortium study, McLean Screening Instrument (MSI), Community Assessment of Psychic Experiences (CAPE-42) and Trauma and Distress Scale (TADS) were filled in by patients with mood disorders (n = 282) in psychiatric care. Correlation coefficients between total scores of scales and their dimensions were estimated, multiple regression and mediation analyses were conducted.ResultsTotal scores of MSI correlated strongly with scores of the CAPE-42 dimension “frequency of positive symptoms” (rho = 0.56; p ≤ 0.001) and moderately with scores of TADS (rho = 0.4; p ≤ 0.001). Total score of MSI and its dimension “cognitive symptoms”, including identity disturbance, distrustfulness and dissociative symptoms, fully mediated the relation between TADS and CAPE-42. Each cognitive symptom showed a partial mediating role (dissociative symptoms 43% (CI = 25–74%); identity disturbance 40% (CI = 30-73%); distrustfulness 18% (CI = 12-50%)).ConclusionsSelf-reported cognitive-perceptual symptoms of BPD fully mediate, while affective, behavioural and interpersonal symptoms only partially mediate the relationships between CEs and PEs. Recognition of co-morbid features of BPD in patients with mood disorders reporting PEs is essential.

- Anorexia nervosa is a complex pathology that has been studied through different paradigma (Onnis, 2004; Treasure, Schimdt, van Furth, 2006). The different authors who studied anorexia nervosa seem to agree about the hypothesis of a multi-factors pathogenesis in which a very important role is played by the relational aspects and, specifically, by family relationships, in the beginning and in the going on of this pathology. Nevertheless, Reiss (1989) pointed out we have to consider both practising and represented family, that is the role of family relationships (i.e. observed interactions) and individual representations. The practising family has been studied by systems theory paradigm, which found very typical transactional patterns in anorexic families, such as enmeshment and triangulation (Minuchin et al., 1980; Selvini Palazzoli et al., 1988; 1998). On the other hand, attachment theory studied the represented family and the role of insecure attachment models in psychopathology onset (Bowlby, 1973; Main, 1996). Many studies have underlined the prevalence of insecure attachment models and unresolved attachment status in response to loss or to trauma in anorexic patients and their mothers, pointing out the role of transgenerational transmission (Cole-Detke, Kobak, 1996; Fonagy et al., 1996; Ward et al., 2001; Ammaniti, Mancone, Vismara, 2001; Ramaciotti, Sorbello, Pazzagli, Vismara, Mancone, Pallanti, 2001).Key-words: anorexia nervosa, adolescence, family, relationships, internal working models.Parole-chiave: anoressia nervosa, adolescenza, famiglia, relazioni, modelli operativi interni.

Background Environment factors affects to the clinical phenotype of schizophrenia spectrum disorders. Aim To develop recommendations for the prevention schizophrenia spectrum disorders considering the influence of environment factors on the clinical pathomorphosis of the disease. Methods It was conducted the psychopathological and psychodiagnostic survey of 186 patients with schizophrenia spectrum disorders with an assessment of clinical features and level of social functioning. It was identified factors that have the most significant pathological effects on the course of disorders on the basis of the received data: the using of a cannabinoid in a family history, mother`s infectious and somatic diseases during pregnancy, mother's using alcohol during pregnancy, consumption of alcohol in adolescent patients, fetal hypoxia or perinatal trauma of the patient at birth, problems with the group of primary support in the family of a child in childhood, maternal toxicosis, crisis relationships in the family, migration to different cultural environment. Results Clinical pathomorphism of disorders of the spectrum of schizophrenia under the influence of environment factors determines the features of psychotherapeutic interventions. In people with cannabinoids, it is important to eliminate the symptoms of anxiety through emotion-supportive measures, as well as to create a motivation to ask help in case of symptoms of schizophrenia spectrum disorders. In a group with perinatal complications, the emphasis should be put on cognitive methods in order to correct mental disorders and overcome hypochondria. Early measures to form a positive attitude towards themselves and the environment, supporting family relationships, overcoming depressive symptoms, and developing social activity are targets of psychotherapeutic interventions in people with schizophrenic spectrum disorders and psychological traumatic events. Conclusion Minimization of environmental factors influence in high risk individuals would postpone early manifestation, reduce disability in patients with schizophrenia spectrum disorders, as evidenced by the statement of leading health experts.

The article deals with and characterizes degrees of vaginismus expression, present in a number of classifications, and contains characteristics of the phobic and hysteric (conversion) forms of vaginismus. It presents a clinical case, which contains a detailed description of psychotraumatic circumstances that resulted in phobic vaginismus and supported its existence, as well as a case of penis captivus in a female patient supervised by the author of this article. Self-perception of the women, suffering from vaginismus, and their family and parental environment are described. In particular it is informed that in many women with vaginismus their fathers were extremely critical, imperious, moralistic and threatening. At the same time, they were sexually seductive with their daughters to an excessive degree. It seemed that in some specific way the daughter substituted for her mother. The fathers behaved like jealous lovers, when their daughters went around with men. On the one hand, they were moralists, but on the other one they extremely concerned themselves with sexuality of their daughters. Also the article points out that half of the patients with vaginismus have alexithymia and discusses the issue of causal relationships between these two conditions. Data about a high rate of comorbid psychic disorders in patients with vaginismus, characteristics of sex partners of women with the above pathology, their responses to the existing disorder as well as information about their sexual dysfunctions are presented. Besides, findings of instrumental physiological examinations (electromyography – EMG) are presented; these demonstrate that women with vaginismus reveal an increased activity of muscles in their pelvic floor both at rest and during induction of vaginismus. The article also contains data, according to which vaginismus is associated with hystrionic-hysterical character traits and sexual distress.

AimsA number of studies sought to explore and define families needs, experiences and concerns associated with being a carer for a detained person and their interaction with Forensic services (McKeown et al, 1995, MacInnes et al, 2002, Tsang et al, 2002, Absalom et al, 2012 Horberg et al, 2015).Relatives can be victims of the service user's offence (Ferriter & Huband, 2003, Tsang et al 2002), and may even blame the service user for their behaviour (Barrowclough et al., 2005). Service user becomes violent and aggressive family members are less likely to be motivated to participate, due to the service user's behaviour (MacInnes, 2000).An initial domestic violence survey of in-patient case files found that in 66%of the patients files, there were reported incidents of domestic violence in family caring relationships prior to the index offence and subsequent admission to NFMHS (Cooney, 2018).MethodA quantitative methodology was used. A domestic violence survey of referrals was conducted of 100 referrals to the National Forensic Mental Health Services – Mental Health and Intellectual & Development Disability Services between 2016-2019.Result22% of the referrals reported Domestic Violence in the family care-giving relationships.The father was recorded as the parent to be experience most Domestic Violence; 40%. Other family members who experienced domestic violence ranged from the mother 32%, brother 12% and sister 8%. Other family members were 8%.100% of the referrals did not report the domestic violence in the carer relationships, nor did referring agencies recorded safeguarding adults concerns.ConclusionThe findings from this audit raises a couple of clinical, legal and safeguarding adults work in National Forensic Mental Health Services with regards to family work. Firstly, the need to (re)conceptualising family work in the context of trauma informed care. Secondly, family work should offer some families, who are victim of crime, a restorative approach. Thirdly, safeguarding adults will need to consider complex caring relationships and acknowledged this as part of care planning and support.

BACKGROUND: Acne vulgaris can severely affect social and psychological functioning. OBJECTIVE: The aim of this study was to investigate the impact of acne vulgaris and its severity on Quality of Life of young adolescents in Greece. METHODS: We conducted a questionnaire based survey among 1560 adolescent between the ages of 11 and 19 years old and 1531 of these were completed. Adolescents with acne filled all the questions including the Children Dermatology Life Quality Index. Adolescents without acne filled the questions about age, family history of acne, stress and smoking. Data were analyzed with Pearson Chi Square test. RESULTS: Acne prevalence was 51.2% affecting both sexes equally. Self reported mild acne was present in 71.2% and moderate-severe acne in 28.8% of the study population. The mean age of the study population was 15.77y. The median score of Children Dermatology Life Quality Index was 4.02. The impact of acne on quality of life is associated with the severity of the acne (p<0.0001). Patients with moderate/severe acne experience greater psychosocial and emotional impairment (p<0.0001). Body image is modified proportionally to the severity of acne (p<0.0001). Symptoms and treatment of acne are factors that also influence their quality of life. Girls and boys are equally affected. Stress and heredity are correlated with acne and its severity (p<0.0001). We didn't find any correlation between smoking and acne. CONCLUSION: Acne affects Quality of Life of young adolescents in Greece. The impact is proportional to the severity of acne. More severe acne is associated with greater effect on quality of life with implications for self esteem, body image and relationships with others.

Social psychiatry starts from the position that as social animals, the cause, course and response to treatment of mental health problems are powerfully determined by the social environment. For example, childhood trauma within the home and bullying at school is associated with both internalizing and externalizing disorders and exerts its influence through life-long impacts on the individual's ability to form supportive relationships with others, their self-esteem and their resilience in the face of future adversity. Difficulties forming and sustaining personal relationships are intensified by the emergence of illness, consequent social exclusion and discrimination that in turn intensifies damaging beliefs of low self-worth and rejection. In contrast, we have considerable evidence for the “therapeutic” value of good relationships, notably the role of family and social support in the remarkable resilience shown by those who have come through the most appalling environmental and personal crises. It is therefore surprising that the balance of psychiatric therapeutic effort is stubbornly focused on the individual patient as the problem with less attention paid to developing and implementing social interventions targeted at the family and wider social network to prevent and alleviate mental illness. In this presentation I will argue that psychiatrists should be more active in developing and leading interventions that focus on the social and interpersonal networks of their patients with illustrations from past and ongoing efforts to this end.Disclosure of interestThe author has not supplied his declaration of competing interest.

The article describes the main psychotherapeutic targets and individual psychological characteristicsof cancer patients with comorbid post-traumatic stress disorder (PTSD), using the example of breast cancer, prostate cancer, and rectal cancer patients in remission following surgery (mastectomy, prostatectomy, and colostomy). The study was carried out at N. N. Petrov Research Institute of Oncology. The experimental group consisted of 40 patients with breast cancer, 32 patients with prostate cancer, and 19 patients with rectal cancer, in accordance with the selection criteria and based on a specialized questionnaire designed to detect symptoms of post-traumatic stress disorder (Trauma Screening Questionnaire). A control group, for comparison, was comprised of 51 women with breast cancer, 53 patients with prostate cancer, and 22 patients with rectal cancer who showed signs of constructively coping with cancer. The assessment of individual psychological characteristics of patients in these nosological groups was carried out using a battery of experimental psychological techniques. In order to enhance the adaptive capacity of the personality in patients with oncological diseases, to prevent the likelihood of developing PTSD, and develop the effectiveness of treatment, the following general psychotherapeutic targets were identified: intrapsychic maladaptive type of response to the disease, excessive fixation on the disease and care during illness; low risk tolerance manifested by patients’ reluctance to act in the absence of reliable guarantees of success; destructive and deficient personality functions; shortage of positive cognitive representations of the world and themselves; destructive guilt associated with the illness and family relationships; excessive desire for autonomy and independence that reduces the possibility of receiving social support.

Background: Hepatitis B virus (HBV) infection has a high prevalence rate in Nigeria. Disclosure of infection status to close partner and the public attracts support for infected people. This study looks at disclosure and social challenges of infected persons. Methods: Mixed methods of patients’ administered questionnaire and an in-depth interview conducted on HBV-infected respondents in a hospital in Nigeria were used. The study recruited all participants who satisfied the inclusion criteria. Data were entered into SPSS version 20 and analyzed using simple and inferential statistics and content analysis for the in-depth interview. Results: A total of 205 participants completed the questionnaire study. Mean (standard deviation) age was 35.3 (±11.0) years. There were 121 married, 37 singles with noncohabiting partners and 47 singles without partners with disclosure rates being 96.7% versus 97.9% versus 89.2%, respectively. Singles disclosed infection more to their parents while married respondents disclosed infection more to their spouses. Singles had high rate of denial of sexual relationship (22.6%), emotional trauma (34.5%), broken relationships (11.4%), and surreptitious use of contraception for protection (67.6%). Married respondents had the highest rate of HBV vaccination of their family members (40.1%). Infection prevention and allaying fears of family members were their counseling needs. In-depth interview revealed that infected respondents usually expressed shock and depression at a positive test leading to fear and deception that put close associates at risk. Conclusion: Hepatitis B virus–infected respondents have high rate of disclosure. Family problems of these people can therefore be solved through public enlightenment and individual counseling.

<p><strong>Background.</strong> A large number of adolescents meet criteria for ‘dual diagnosis’ (a psychiatric disorder plus co-morbid substance use disorder (SUD), which prolongs treatment response and complicates intervention strategies. The current service model in Cape Town divides the care of such patients into psychiatric treatment and a separate substance use intervention. Child and adolescent mental health services face the challenge of high rates of readmission of adolescents into psychiatric facilities before utilisation of community-based substance abuse services.</p><p><strong>Objective.</strong> There is a scarcity of available treatment guidelines for dual-diagnosis adolescents, and a lack of systematically documented epidemiological and clinical data in South African adolescent populations.</p><p><strong>Method.</strong> A retrospective chart review of adolescent psychiatric admissions to the Tygerberg Adolescent Psychiatric Unit during 2010 was conducted. Relevant epidemiological, clinical and demographic data for those presenting with a dual diagnosis (specifically psychotic disorders and SUD) was recorded.<strong> </strong></p><p><strong>Results.</strong> Results suggest a high prevalence of SUD among adolescents presenting with a first-episode psychosis. Statistically significant correlations with lower levels of education were found in those with ongoing substance abuse (specifically cannabis and methamphetamine), and a significant relationship between choice of debut drug and ongoing drug use was also demonstrated. Risk factors for SUD (psychosocial adversities, childhood trauma, family and community exposure to substances, early debut drug ages), risky sexual behaviours, and clinical psychiatric profiles of adolescents with dual diagnosis are described.</p><p><strong>Conclusions.</strong> This cohort had an enhanced risk as a result of genetic vulnerability and environmental availability of substances, and the findings emphasise the differences in presentation, choice of drugs of abuse and psychosocial difficulties of adolescents with a dual diagnosis presenting to a psychiatric facility. We aim to influence role-players to provide more integrated services, and highlight the need for future prospective studies in this adolescent group to assist in improving outcomes.</p>

Abstract Background It can be challenging for general practitioners to support their oldest old patients through the complex process of relocation. Objective To provide a typology of the experiences of moving in very old age that is clinically useful for practitioners navigating very old people’s relocation. Methods Qualitative analysis of data from a mixed-methods UK population-based longitudinal study, Cambridge City over-75s Cohort (CC75C), from Year 21 follow-up onwards. Interviews with participants aged ≥95 years old and proxy informants (Year 21: 44/48, 92%, subsequent attrition all deaths). Thematic analysis of qualitative data available from 26/32 participants who moved before they died. Results Individuals who moved voluntarily in with family experienced gratitude, and those who moved into sheltered house or care homes voluntarily had no regrets. One voluntary move into care was experienced with regret, loss and increased isolation as it severed life-long community ties. Regret and loss were key experiences for those making involuntary moves into care, but acceptance, relief and appreciation of increased company were also observed. The key experience of family members was trauma. Establishing connections with people or place ahead of moving, for example through previous respite care, eased moving. A checklist for practitioners based on the resulting typology of relocation is proposed. Conclusions Most of the sample moved into residential care. This study highlights the importance of connections to locality, people and place along with good family relationships as the key facilitators of a healthy transition into care for the oldest old. The proposed checklist may have clinical utility.

IntroductionThe eating disorder are not only isolated power problems. They interweave issues and pathologies in patients often difficult to approach and have crimping going to reach a solution and get to the real problem of the patient. As it has been observed in studies if they have established relationships between patients with an impulsive nature and traumatized regarding the presentation of eating disorders.ObjectivesOur study aims to establish the relationship between eating disorder such as anorexia and bulimia with factors such as impulsivity and suffered traumas.Materials and methodsIt has used a sample (n = 57) and patients spent three scales “Barratt Impulsiveness Scale” (BIS-11), “Questionnaire traumatic experiences” (TQ) and the BSQ, scale measuring dissatisfaction disorders eating behavior. The aim is to see the relationship between anorexia and bulimia regarding trauma and impulsivity.ResultsIt is intended to check if having character traits of impulsivity or miss having lived or suffered traumatic experiences such as the unexpected death of a family member, rape, kidnapping… establishes a relationship in patients who develop conduct disorders food.ConclusionThis study aims to see if there is a correlation between eating disorder and factors such as traumatic experiences and an influential feature in this pathology such as the impulsivity through a sample of patients (n = 57) over 18 years.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. Cutcliffe JR, Stevenson C, Jackson S, et al. A modified grounded theory study of how psychiatric nurses work with suicidal people. Int J Nurs Studies 2006:43(7):791–802.16. Lakeman, R. What can qualitative research tell us about helping a person who is suicidal? Nurs Times 2010:106(33):23–26.17. Karman P, Kool N, Poslawsky I, et al. Nurses’ attitudes toward self-harm: a literature review. J Psychiatr Ment Health Nurs 2015:22:65–75.18. Carter B. ‘One expertise among many’ – working appreciatively to make miracles instead of finding problems: Using appreciative inquiry as a way of reframing research. J Res Nurs 2006:11(1): 48–63.19. Lieblich A, Tuval-Mashiach R, Zilber T. Narrative research: Reading, analysis, and interpretation. Sage Publications; 1998.20. Braun V and Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006:3(2):77–101.21. Kishi Y, Otsuka K, Akiyama K, et al. Effects of a training workshop on suicide prevention among emergency room nurses. Crisis 2014:35(5):357–61.

AbstractObjective:One of the most prevalent life-threatening illnesses is heart disease. The initial trauma of being diagnosed with a life-threatening illness or having a cardiac event can begin a psychosocial chain reaction that results in a transformation of the lives of these patients. The goal of our study was to investigate the lived experiences of psychosocial healing in rehabilitation of cardiac patients using a qualitative written interview.Method:A purposive sample of 14 cardiac event survivors was recruited. Participants were interviewed after informed consent and screening. We used a qualitative analysis and model-revision approach similar to the procedure outlined by Charmaz (2006).Results:Participants consistently mentioned that a heightened awareness of mortality was a motivating factor that led to participants focusing more on their family and relationships, having an enhanced outlook on life, and making healthy lifestyle changes.Significance of results:If clinicians are able to employ a measure to better understand the nature of a patient's progression from cardiac event to successful recovery, interventions such as cardiac rehabilitation can be implemented earlier and more effectively during the course of the illness and recovery phases of treatment. Theoretically, this early detection of a patient's progression could reduce the time spent recovering from a cardiac event, and it would allow treatments for these conditions to better alleviate the psychosocial concerns faced by patients.

Psychosocial rehabilitation for patients with mental disorders is one of the priority areas of scientific research in modern psychiatric discourse. The key to solving this problem is a multidisciplinary approach, within which it becomes possible to select congruent rehabilitation and psychoeducational techniques, taking into account the clinical and psychopathological content of this nosological form. In this context endogenous procedural mental disorders deserve special attention, as they are characterized by the highest level of social and labor maladjustment. Aim. To investigate the effectiveness of the developed model of complex psychosocial rehabilitation for patients with schizophrenia. Materials and methods. On the basis of Municipal Non-Commercial Enterprise “Regional Clinical Institution for Provision of Psychiatric Care” of Zaporizhzhia Regional Council, 80 patients with a simple form of schizophrenia were selected at the outpatient stage of treatment for the purpose of further examination. Clinical diagnostics of the studied mental pathology was carried out in accordance with the differential diagnostic criteria of the International Classification of Diseases 10 revision (ICD-10). The inclusion criteria for the study contingent were: informed consent to participate in the study, the absence of severe somatic pathology and information about craniocerebral trauma. In order to analyze the effectiveness of the developed model, the study contingent was randomized into the study group (SG) – 40 patients who received complex therapy within the framework of the developed model of psychosocial rehabilitation, and the comparison group (CG) – 40 patients who received treatment in accordance with the current protocols. Results. Based on the formed principles of psychosocial rehabilitation for patients with a simple form of schizophrenia, a comprehensive model of psycho-rehabilitation support for this patient contingent was generated including four stages: psychopharmacological, family intervention, cognitive-behavioural and ergotherapeutic. Analysing the effectiveness of the developed model, statistically significant differences (P < 0.05) were established between the average indicators in the studied groups according to the criteria “socially useful activity, including work and study” (4.18 ± 0.25 and 3.33 ± 0.27 points in SG and CG, respectively) and “relationships with family and other social relations” (4.35 ± 0.24 and 3.60 ± 0.25 points in SG and CG, respectively) in the absence of statistically significant differences in the criteria for “self-care” and “bothering others and aggressive behaviour”. Conclusions. The effectiveness of the complex model of psychosocial rehabilitation for patients with a simple form of schizophrenia in the areas of socially useful activities (study and work) and social relations was developed and proved, which made it possible to increase the effectiveness of therapy for this contingent of patients.

A common problem for otolaryngologists are patients who present with recurrent, persistent sinus pain that appears out of proportion to the findings on physical examination. Often these patients have a history of recurrent sinusitis that required antibiotics or surgical intervention. Many have had repeated surgical procedures because of this pain. Other common past medical histories may include allergic rhinitis, facial trauma, or dental disease. Patients who have experienced documented acute sinusitis in the past will often present de novo with similar symptoms, but lack any objective evidence of a new active sinus infection. However, the diagnosis of sinusitis is not clearly removed from the patient's or clinician's mind, and the patient is further frustrated by the lack of adequate diagnosis, treatment, and resolution of symptoms. These patients may or may not be experiencing an upper respiratory tract infection or allergy with nasal drainage. Often, they are emotionally distraught from recurrent and persistent pain, the lack of resolution of their symptoms, dependency on narcotics and other analgesics, multiple consultations with a variety of clinicians, and the impingement of their symptoms on employment, interpersonal relationships, and societal and family obligations. If sinusitis is not found to be present, the otolaryngologist must help the patient understand this point, reassure him or her that the otolaryngologist will still be vigilant for the development of sinusitis, and refocus the history and workup for some other cause of the recurrent and persistent paranasal pain. We review various treatment approaches to paranasal pains that are not the result of sinusitis.

<p><strong>List of Abstract Titles and authors:<br /></strong></p><p><strong>1. Psychosis: A matter of mental effort?</strong></p><p>M Borg, Y Y van der Zee, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>2.In search of an affordable, effective post-discharge intervention: A randomised control trial assessing the influence of a telephone-based intervention on readmissions for patients with severe mental illness in a developing country</strong></p><p><strong></strong>U A Botha, L Koen, M Mazinu, E Jordaan, D J H Niehaus</p><p><strong>3. The effect of early abstinence from long-term methamphetamine use on brain metabolism using 1H-magnetic resonance spectro-scopy (1H-MRS)</strong></p><p>A Burger, S Brooks, D J Stein, F M Howells</p><p><strong>4. The effect of <em>in utero exposure </em>to methamphetamine on brain metabolism in childhood using 1H-magnetic resonance spectroscopy (1H-MRS)</strong></p><p>A Burger, A Roos, M Kwiatkowski, D J Stein, K A Donald, F M Howells</p><p><strong>5. A prospective study of clinical, biological and functional aspects of outcome in first-episode psychosis: The EONKCS Study</strong></p><p><strong></strong>B Chiliza, L Asmal, R Emsley</p><p><strong>6. Stimulants as cognitive enhancers - perceptions v. evidence in a very real world</strong></p><p><strong></strong>H M Clark</p><p><strong>7. Pharmacogenomics in antipsychotic drugs</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>8. Serotonin in anxiety disorders and beyond</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>9. HIV infection results in ventral-striatal reward system hypo-activation during cue processing</strong></p><p><strong></strong>S du Plessis, M Vink, J A Joska, E Koutsilieri, A Bagadia, D J Stein, R Emsley</p><p><strong>10. Disease progression in schizophrenia: Is the illness or the treatment to blame?</strong></p><p>R Emsley, M J Sian</p><p><strong>11. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p> S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>12. Iron deficiency in two children diagnosed with multiple sclerosis: Report on whole exom sequencing</strong></p><p><strong></strong>S Janse van Rensburg, R van Toorn, J F Schoeman, A Peeters, L R Fisher, K Moremi, M J Kotze</p><p><strong>13. Benzodiazepines: Practical pharmacokinetics</strong></p><p><strong></strong>P Joubert</p><p><strong>14. What to consider when prescribing psychotropic medications</strong></p><p><strong></strong>G Lippi</p><p><strong>15. Current prescribing practices for obsessive-compulsive disorder in South Africa: Controversies and consensus</strong></p><p><strong></strong>C Lochner, L Taljaard, D J Stein</p><p><strong>16. Correlates of emotional and behavioural problems in children with preinatally acquired HIV in Cape Town, South Africa</strong></p><p><strong></strong>K-A Louw, N Phillips, JIpser, J Hoare</p><p><strong>17. The role of non-coding RNAs in fear extinction</strong></p><p><strong></strong>S Malan-Muller, L Fairbairn, W M U Daniels, M J S Dashti, E J Oakleley, M Altorfer, J Harvey, S Seedat, J Gamieldien, S M J Hemmings</p><p><strong>18. An analysis of the management og HIV-mental illness comorbidity at the psychiatric unit of the Dr George Mukhari Academic Hospital</strong></p><p><strong></strong>M L Maodi, S T Rataemane, T Kyaw</p><p><strong>19. The identification of novel genes in anxiety disorders: A gene X environment correlation and interaction study</strong></p><p><strong></strong>N W McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D J Stein, V Russel, C Lochner</p><p><strong>20. Collaborations between conventional medicine and traditional healers: Obstacles and possibilities</strong></p><p><strong></strong>G Nortje, S Seedat, O Gureje</p><p><strong>21. Thought disorder and form perception: Relationships with symptoms and cognitive function in first-episode schizophrenia</strong></p><p>M R Olivier, R Emsley</p><p><strong>22. Investigating the functional significance of genome-wide variants associated with antipsychotic treatment response</strong></p><p><strong></strong>E Ovenden, B Drogemoller, L van der Merwe, R Emsley, L Warnich</p><p><strong>23. The moral and bioethical determinants of "futility" in psychiatry</strong></p><p><strong></strong>W P Pienaar</p><p><strong>24. Single voxel proton magnetic resonance spectroscopy (1H-MRS) and volumetry of the amylgdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A T Hess, J Zwart, F Ahmed-Leitao, E Meintjies, S Seedat</p><p><strong>25. Schizoaffective disorder in an acute psychiatric unit: Profile of users and agreement with Operational Criteria (OPCRIT)</strong></p><p><strong></strong>R R Singh, U Subramaney</p><p><strong>26. The right to privacy and confidentiality: The ethics of expert diagnosis in the public media and the Oscar Pistorius trial</strong></p><p><strong></strong>C Smith</p><p><strong>27. A birth cohort study in South Africa: A psychiatric perspective</strong></p><p>D J Stein</p><p><strong>28. 'Womb Raiders': Women referred for observation in terms of the Criminal Procedures Act (CPA) charged with fetal abduction and murder</strong></p><p><strong></strong>U Subramaney</p><p><strong>29. Psycho-pharmacology of sleep wake disorders: An update</strong></p><p>R Sykes</p><p><strong>30. Refugee post-settlement in South Africa: Role of adjustment challenges and family in mental health outcomes</strong></p><p><strong></strong>L Thela, A Tomita, V Maharaj, M Mhlongo, K Jonathan</p><p><strong>31. Dstinguishing ADHD symptoms in psychotic disorders: A new insight in the adult ADHD questionnaire</strong></p><p>Y van der Zee, M Borg, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>32. Oscar Pistorius ethical dilemmas in a trial by media: Does this include psychiatric evaluation by media?</strong></p><p>M Vorster</p><p><strong>33. Genetic investigation of apetite aggression in South African former young offenders: The involvement of serotonin transporter gene</strong></p><p>K Xulu, J Somer, M Hinsberger, R Weierstall, T Elbert, S Seedat, S Hemmings</p><p><strong>34. Effects of HIV and childhood trauma on brain morphemtry and neurocognitive function</strong></p><p>G Spies, F Ahmed-Leitao, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>35. Measuring intentional behaviour normative data of a newly developed motor task battery</strong></p><p><strong></strong>S Bakelaar, J Blampain, S Seedat, J van Hoof, Y Delevoye-Turrel</p><p><strong>36. Resilience in social anxiety disorder and post-traumatic stress disorder in the context of childhood trauma</strong></p><p>M Bship, S Bakelaar, D Rosenstein, S Seedat</p><p><strong>37. The ethical dilemma of seclusion practices in psychiatry</strong></p><p>G Chiba, U Subramaney</p><p><strong>38. Physical activity and neurological soft signs in patients with schizophrenia</strong></p><p>O Esan, C Osunbote, I Oladele, S Fakunle, C Ehindero</p><p><strong>39. A retrospective study of completed suicides in the Nelson Mandela Bay Metropolitan Area from 2008 to 2013 - preliminary results</strong></p><p><strong></strong>C Grobler, J Strumpher, R Jacobs</p><p><strong>40. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p><strong></strong>S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>41. Investigation of variants within antipsychotic candidate pharmacogenes associated with treatment outcome</strong></p><p>F Higgins, B Drogmoller, G Wright, L van der Merwe, N McGregor, B Chiliza, L Asmal, L Koen, D Niehaus, R Emsley, L Warnich</p><p><strong>42. Effects of diet, smoking and alcohol consumption on disability (EDSS) in people diagnosed with multiple sclerosis</strong></p><p>S Janse van Rensburg, W Davis, D Geiger, F J Cronje, L Whati, M Kidd, M J Kotze</p><p><strong>43. The clinical utility of neuroimaging in an acute adolescnet psychiatric inpatient population</strong></p><p><strong></strong>Z Khan, A Lachman, J Harvey</p><p><strong>44. Relationships between childhood trauma (CT) and premorbid adjustment (PA) in a highly traumatised sample of patients with first-episode schizophrenia (FES</strong>)</p><p>S Kilian, J Burns, S Seedat, L Asmal, B Chiliza, S du Plessis, R Olivier, R Emsley</p><p><strong>45. Functional and cognitive outcomes using an mTOR inhibitor in an adolescent with TSC</strong></p><p>A Lachman, C van der Merwe, P Boyes, P de Vries</p><p><strong>46. Perceptions about adolescent body image and eating behaviour</strong></p><p><strong></strong>K Laxton, A B R Janse van Rensburg</p><p><strong>47. Clinical relevance of FTO rs9939609 as a determinant of cardio-metabolic risk in South African patients with major depressive disorder</strong></p><p>H K Luckhoff, M J Kotze</p><p><strong>48. Childhood abuse and neglect as predictors of deficits in verbal auditory memory in non-clinical adolescents with low anxiety proneness</strong></p><p>L Martin, K Martin, S Seedat</p><p><strong>49. The changes of pro-inflammatory cytokines in a prenatally stressed febrile seizure animal model and whether <em>Rhus chirindensis</em> may attenuate these changes</strong></p><p><strong></strong>A Mohamed, M V Mabandla, L Qulu</p><p><strong>50. Influence of TMPRSS6 A736v and HFE C282y on serum iron parameters and age of onset in patients with multiple sclerosis</strong></p><p><strong></strong>K E Moremi, M J Kotze, H K Luckhoff, L R Fisher, M Kidd, R van Toorn, S Janse van Rensburg</p><p><strong>51. Polypharmacy in pregnant women with serious mental illness</strong></p><p>E Thomas, E du Toit, L Koen, D Niehaus</p><p><strong>52. Infant attachment and maternal depression as predictors of neurodevelopmental and behavioural outcomes at follow-up</strong></p><p>J Nothling, B Laughton, S Seedat</p><p><strong>53. Differences in abuse, neglect and exposure to community violence in adolescents with and without PTSD</strong></p><p><strong></strong>J Nothling, S Suliman, L Martin, C Simmons, S Seedat</p><p><strong>54. Assessment of oxidative stress markers in children with autistic spectrum disorders in Lagos, Nigeria</strong></p><p><strong></strong>Y Oshodi, O Ojewunmi, T A Oshodi, T Ijarogbe, O F Aina, J Okpuzor, O C F E A Lesi</p><p><strong>55. Change in diagnosis and management of 'gender identity disorder' in pre-adolescent children</strong></p><p>S Pickstone-Taylor</p><p><strong>56. Brain network connectivity in women exposed to intimate partner violence</strong></p><p>A Roos, J-P Fouche, B Vythilingum, D J Stein</p><p><strong>57. Prolonged exposure treatment for PTSD in a Third-World, task-shifting, community-based environment</strong></p><p>J Rossouw, E Yadin, I Mbanga, T Jacobs, W Rossouw, D Alexander, S Seedat</p><p><strong>58. Contrasting effects of early0life stress on mitochondrial energy-related proteins in striatum and hippocampus of a rat model of attention-deficit/ hyperactivity disorder</strong></p><p><strong></strong>V Russell, J Dimatelis, J Womersley, T-L Sterley</p><p><strong>59. Attention-deficit hyperactivity disorder in adults: A South African perspective</strong></p><p>R Schoeman, M de Klerk, M Kidd</p><p><strong>60. Cognitive function in women with HIV infection and early-life stress</strong></p><p>G Spies, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>61. Changes in functional connectivity networks in bipolar disorder patients after mindfulness-based cognitic therapy</strong></p><p>J A Starke, C F Beckmann, N Horn</p><p><strong>62. Post-traumatic stress disorder, overweight and obesity: A systematic review and meta-analysis</strong></p><p><strong></strong>S Suliman, L Anthonissen, J Carr, S du Plessis, R Emsley, S M J Hemmings, C Lochner, N McGregor L van den Heuvel, S Seedat</p><p><strong>63. The brain and behaviour in a third-trimester equivalent animal model of fetal alcohol spectrum disorders</strong></p><p>P C Swart, C B Currin, J J Dimatelis, V A Russell</p><p><strong>64. Irritability Assessment Model (IAM) to monitor irritability in child and adolescent psychiatric disorders.</strong></p><p>D van der Westhuizen</p><p><strong>65. Outcome of parent-adolescent training in chilhood victimisation: Adaptive functioning, psychosocial and physiological variables</strong></p><p>D van der Westhuizen</p><p><strong>66. The effect of ketamine in the Wistar-Kyoto and Sprague Dawley rat models of depression</strong></p><p>P J van Zyl, J J Dimatelis, V A Russell</p><p><strong>67. Investigating COMT variants in anxiety sensitivity in South African adolescents</strong></p><p>L J Zass, L Martin, S Seedat, S M J Hemmings</p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p><strong><br /></strong></p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p>

Abstract Introduction Through previous studies and conferences, it was noted that medical errors perceived by haemophilia A (HA) carriers often resulted in poor relationships with health care providers (HCPs; principally physicians and nurses), and lead to reports of unfortunate and extreme emotional and behavioural responses. To explore the range medical experiences and responses of HA carriers, we undertook this qualitative study. M&M Interested members of the Canadian Haemophilia Society participated in semi-structured interviews. Nine adult interviewees (8 HA carriers, 1 non-carrier) discussed 11 carriers (7 adults, 4 children). A qualitative review exploring themes from anonymized interview transcripts was done using QSR NVIVO 8.0. Transcripts were coded for carrier symptoms, medical care experiences, perceived correctness of care, attitude of the caregiver, and emotional and behavioural responses. Results Nine of 11 carriers had experienced serious bleeds such as spontaneous bleeds, excessive post-operative or post-partum bleeding, or joint bleeds following mild to moderate trauma. Ten carriers had experienced symptoms of excess bleeding. All adult carriers reported heavy or prolonged menstrual bleeding. However, only 3 were reported as registered in a haemophilia treatment centre, and only one was regularly followed. Three carried factor first cards and four wore medic alert bracelets. 153 medical care experiences were discussed including 78 described as errors or deficiencies in care. HCP attitude was described as negative in 38 of 81 experiences. Interviewees felt that their concerns were trivialized, symptoms down-played, and they were not believed. In response, interviewees relayed deep feelings of disappointment, frustration, desperation, and complete loss of respect for the medical system. Other symptomatic carriers expressed self-doubt. Most often expressed was mistrust, disappointment, or loss of confidence in HCPs (8 of 9 interviewees, 46 instances), or anger (8 of 9 interviewees, 33 instances). Fear or anxiety was also commonly relayed (7 of 9 interviewees, 32 instances). Self-advocacy was the most common behavioural response (9 of 9 interviewees, 49 instances). Extreme behaviour included complete avoidance of the healthcare system (14 instances), and diagnosing and treating serious bleeds without medical supervision. Interviewees believed there was insufficient knowledge about bleeding disorders in women among HCPs (5 of 9 interviewees), insufficient knowledge about gynaecological norms among HCPs and patients (3 of 9), reticence of carriers to discuss personal gynaecological problems (2 of 9), and down-playing by carriers of their own symptoms as compared to more severely affected males (4 of 9). Interviewees often related errors in the care of family members and non-family members. Experiences shared within and among families affirmed their concepts of appropriate care and reinforced perceptions of inadequate care. Conclusions The bleeding disorder that affects HA carriers is a unique issue of women and children. HA carriers can experience serious bleeds and report numerous errors in medical management and negative attitudes toward their concerns. Their experiences often result in strong emotional responses, mistrust of the medical system, and some extreme and potentially detrimental behaviours. Solutions to these problems could include widely circulated management principles endorsed by both HCP and HA carrier groups, improved communication and education, registration of carriers in haemophilia treatment centres or women’s bleeding disorder clinics, and improved communication with the wider haemophilia community to rebuild a positive relationship of trust with the medical care system.

The paper looks at the exploration in three Indian novels in English, of the hitherto glorified Indian family through the paradigm of dementia, examines the strained space called “home” in the shadow of dementia, and its transformation into a recuperative space with the help of support systems other than immediate family members. These three recent texts have discussed this crippling condition; which earlier authors shied away from. Anuradha Roy’s The Folded Earth (2012), Ranjit Lal’s Our Nana was a Nutcase (2015), and Pankaj Varma’s Silver Haze (2014), focus on the life-changing effects of the deadly disease dementia. These literary texts opt for a non-medical approach through which the person suffering dementia is depicted, rather than dementia itself. The family becomes a narrative prism through which to view the changing equations in relationships, the erosion of the family structure, instead of the specific medical condition. In conclusion, one could say that families become the recuperative space for patients rather than medical facilities for long term care. These writers do not focus much on the medicalisation of dementia or geriatric health issues. They do mention medical treatments, but the spotlight is on the family, not on clinical viewpoints or medical approaches.

Schizophrenia is disorders associated with psychosis consisting of a group of clinical syndromes that are expressed with abnormalities in the contents of thought organizations, interpretation of sensory input, affective / emotional tension, will identity, psychomotor behavior, and the ability to establish satisfying interpersonal relationships. The purpose of this study was to study the relationship between the history of psychological trauma and the incidence of social isolation in schizophrenic patients at Soeprapto Mental Hospital in Bengkulu Province. This type of research is observational analytic using correlational design and using total sampling techniques with inclusion and exclusion criteria for 40 respondents. The population of this study was in schizophrenia patients at Soeprapto Mental Hospital, Bengkulu Province. Date collection techniques with primary and Secondary. Results: From 40 people there were 9 people (22.5%) had a history of psychological trauma, 31 people (77.5%) had no history of psychological trauma, from 40 people there were 16 people (40.0%) social isolation and 24 people (60.0%) did not have social isolation, there was a history of psychological trauma and the incidence of social isolation in schizophrenic patients at the Soeprapto Mental Hospital in Bengkulu Province. It is hoped that the Soeprapto Mental Hospital of Bengkulu Province can provide appropriate treatment and education by using poster and leaflet media when the patient's family is undergoing treatment and increasing the coaching program for schizophrenia patients so social isolation does not occur.

AbstractObsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD) can take many different forms of presentations. The term ‘complex’ is common and inconsistently used in both OCD and BDD. Practitioners often refer to complex OCD or BDD when patients present with severe co-morbid problems, often in the context of personality difficulties, dissociation, difficult early relationships and trauma; or when the illness is chronic and debilitating with previous multiple treatment failures. Current best-evidence treatment protocols for both disorders focus heavily on exposure and response prevention (E/RP) but with moderate success, particularly in patients who are deemed ‘complex’, and often those with relevant shame and/or disgust-based past experiences. The aim of the present paper is to (a) describe factors that contribute to complexity in OCD and BDD, and (b) link these with theory and practice. We emphasize the importance of understanding both the function of OCD and BDD-related behaviours (rather than the content of obsessions or compulsion), and the context in which they occur such as the family. We illustrate complexity in OCD and BDD using real case material, using a functional and contextual approach to formulate the client's difficulties, and demonstrate how E/RP can be enhanced successfully with imagery rescripting, family work, and compassion-focused therapy.

Chronic pelvic pain affects one in seven women worldwide, and there is an urgent need to reduce its associated significant costs and to improve women's health. There are many correlated factors associated with chronic pelvic pain (CPP), and analyzing them simultaneously can be complex and involves many challenges. A newly developed interaction ensemble, referred to as INTENSE, was implemented to investigate this research gap. When applied, INTENSE aggregates three machine learning (ML) methods, which are unsupervised, as follows: interaction principal component analysis (IPCA), hierarchical cluster analysis (HCA), and centroid-based clustering (CBC). For our proposed research, we used INTENSE to uncover novel knowledge, which revealed new interactions in a sample of 656 patients among 25 factors: age, parity, ethnicity, body mass index, endometriosis, irritable bowel syndrome, painful bladder syndrome, pelvic floor tenderness, abdominal wall pain, depression score, anxiety score, Pain Catastrophizing Scale, family history of chronic pain, new or re-referral, age when first experienced pain, pain duration, surgery helpful for pain, infertility, smoking, alcohol use, trauma, dysmenorrhea, deep dyspareunia, CPP, and the Endometriosis Health Profile for functional quality of life. INTENSE indicates that CPP and the Endometriosis Health Profile are correlated with depression score, anxiety score, and the Pain Catastrophizing Scale. Other insights derived from these ML methods include the finding that higher body mass index was clustered with smoking and a history of life trauma. As well, sexual pain (deep dyspareunia) was found to be associated with musculoskeletal pain contributors (abdominal wall pain and pelvic floor tenderness). Therefore, INTENSE provided expert-like reasoning without training any model or prior knowledge of CPP. ML has the potential to identify novel relationships in the etiology of CPP, and thus can drive innovative future research.

Background: The Multicenter Youth Flexible ACT Study is an ongoing observational prospective cohort study that examines the effects of Youth Flexible ACT (Assertive Community Treatment) on young people with complex care needs who are difficult to engage in traditional (office-based) mental health services. However, a clear and detailed description of this patient group is lacking. In the current paper, we present baseline characteristics and psychosocial outcomes of the Youth Flexible ACT target group and explore the existence of underlying specific patient subgroups.Methods: Sixteen Youth Flexible ACT teams from seven mental healthcare institutes in the Netherlands participated in the study. Research participants were monitored for 18 months and administered questionnaires measuring psychiatric- and social functioning every 6 months, yielding four measurements. Baseline data were obtained from 199 adolescents, their mental health workers, and parents/carers. Latent Class Analysis based on HoNOSCA scores (measuring psychosocial and daily functioning) was conducted to identify underlying subgroups.Results: The target group of Youth Flexible ACT mainly consisted of patients older than 15 years of age with a history of (specialized) mental healthcare. They face many complex problems, including trauma; developmental, mood, and anxiety disorders; and problems with school attendance, family life, and peer relationships. Other frequently reported difficulties were substance misuse, the involvement of the legal system or police, problems with intellectual functioning, and personal finance. Patients were classified into four distinct classes: the “internalizing,” “externalizing,” “non-specific,” and the “overly impulsive” subgroup. Each subgroup had its unique pattern of difficulties and focus, respectively, high levels of depression and anxiety, disruptive behavior, unspecific difficulties, and substance misuse.Conclusions: As expected, patients in Youth Flexible ACT experienced many severe problems, rendering them vulnerable to fragmented and, thus, ineffective care. Our findings underscore the need for an integrated care approach with a multidisciplinary team of skilled professionals that can bridge these wide-ranging psychosocial problems, as each class of participants experienced a different set of difficulties. Youth Flexible ACT teams need to adjust their care services accordingly.

<p>Physiotherapy is considered a healthcare profession concerned with human function and movement, and maximising potential. It normally uses physical approaches to promote, maintain, and restore physical, psychological, and social well-being, taking account of the variations in health status. The human function is more than just a physical and movement issue. Physiotherapy plays a unique role in the rehabilitation of people who have been profoundly traumatised. Certain precautions are needed when handling survivors of torture, but sensitive physical techniques can relieve the legacies of severe pain, dysfunction, and stress. The physical medium is especially effective for people who are unable to speak of their experiences. (<em>Hough, 1992</em>) Trauma, especially those who have experienced torture and considerable life-threatening violence presents a very wide range of responses from an individual - responses that often include family members and close relationships. The <em>Humane to Humane</em> Transcultural Centre for Torture Victims in Manipur has been providing direct assistance to over 450 clients and their families in support with the UN Torture Fund since 2009.</p><p>Working with people who have been tortured has similarities to working with intensive care patients. There is a need for acute sensitivity to the client's responses, an extra awareness of the importance of autonomy, and an understanding of issues of power and helplessness. A multidisciplinary approach was adopted that included medical, psychological, creative movement therapy, social and financial assistance. Physiotherapy constituted an important component of the services provided by the centre, providing a vital link in rebuilding the personality of survivors of torture because trust can be fostered in the context of physical contact. Close liaison between the physiotherapist and other therapists is needed in this area of work. A combined approach is essential in the work and the support team also indulges in caring for each other and the luxury of co-working. The intimacy of our relationship with survivors of torture is matched by the perverted intimacy of their previous relationship with the torturer, and extra care is needed in this context.</p><p>This paper elaborates on the range of psychosocial, physical, and emotional responses to torture, the methodologies adopted, and the results obtained in our centre.</p>

Over a period of ten years Paul Ewing documented the life of his family on film – initially using Super 8 film and then converting to VHS with the advent of the new technology. Through the lens of home movies, autoethnography and memory I discuss his approach to amateur image making and its lasting legacy. Home movies have been the driving force behind a number of autobiographical documentaries such as Tarnation, Video Fool for Love and Stories We Tell. Here I take an auto ethnographical look at the films my own father made over a ten year period, prior to my parents divorce, and examine their impact on my own life and look to see if there is any value to them outside of my own personal investment. “Autoethnography is predicated on the ability to invite readers into the lived experience of the presumed “Other” and to experience it viscerally” (Boylorn and Orbe 15). It is a research method that connects “the autobiographical and personal to the cultural, social and political” (Ellis xix). Autoethnography involves the turning of the ethnographic gaze inward on the self (Denzin 227). Autoethnographers use their personal experience as primary data reflexively to bend back on self and look more deeply at self-other interactions.Paul Francis Ewing was born in 1947 in Redhill in the United Kingdom. Inez Anne Taveira was born eight years previously in another part of the world entirely, Taiping in Malaysia or Malaya as it was known then. She immigrated to the UK when she was 21 to study acting and later teaching. She married Paul in 1970 and by 1976 they had two children – my brother Brendan and myself. Around 1978 Paul, or Dad, started to film the family. He wanted to “capture the moment. Like writing a diary”. Patricia Zimmerman writes, “Amateur film represents psychic tracings of diaries and dreams. The family, dreams, and nightmares create new hybrids, new discourses” (276). In the beginning of the last century Pierre Janet already noted that: "certain happenings ... leave indelible and distressing memories – memories to which the sufferer continually returns, and by which he is tormented by day and by night.” Janet, postulated that intense emotional reactions make events traumatic by interfering with the integration of the experience into existing memory schemes. Intense emotions, Janet thought, cause memories of particular events to be dissociated from consciousness, and to be stored, instead, as visceral sensations (anxiety and panic), or as visual images (nightmares and flashbacks). Schachtel defined it as: “Memory as a function of the living personality can be understood as a capacity for the organization and reconstruction of past experiences and impressions in the service of present needs, fears, and interests” (284).The images captured by Paul Ewing are part of both my consciousness and unconsciousness. I have revisited them on numerous occasions for varying reasons. Amateur film’s otherness requires analysis of active relationships between maker and subject (Zimmerman 277). When I questioned Paul in regards to this research, he suggested that screening the films was very important to him. “Mum and I enjoyed them and then later the grand parents. Also you and Bren.” I found it more than interesting that he placed my brother and myself last in the list of those who enjoyed the screenings. As a student of film I have looked for the stories within these images, looking to understand whom the man behind the lens was: potentially who the men behind the lenses have been. Who was the man from my/our memories, who was the boy, who were the boys who became the man/men we are? Van der Kolk and Fisler suggest that ‘dissociation refers to a compartmentalization of experience: elements of the experience are not integrated into a unitary whole, but are stored in memory as isolated fragments consisting of sensory perceptions or affective states” (510). Karen L. Ishizuka insists, “Within home movies ... lie hidden histories of the world.” In this case, perhaps only hidden histories of myself. Given a consistent dissociative reaction to stressful situations my honest agenda in watching and re-watching my father’s home cinema may indeed be to attempt to decode what Janet claimed people experience when intense emotions, memories cannot be transformed into a neutral narrative: a person is “unable to make the recital which we call narrative memory, and yet he remains confronted by the difficult situation” (660). This results in a phobia of memory that prevents the integration of traumatic events and splits off the traumatic memories from ordinary consciousness. Piaget claimed that dissociation occurs when an active failure of semantic memory leads to the organization of memory on somatosensory or iconic levels (201). It cannot be coincidence that these descriptors sound familiar to any student or practitioner of cinema. We, the automaton: a moving mechanical device made in imitation of a human being.“The limbic system is thought to be the part of the central nervous system that maintains and guides the emotions and behavior necessary for self-preservation and survival of the species, and that is critically involved in the storage and retrieval of memory” (Van der Kolk 10). Of all areas in the central nervous system, the amygdala is most clearly implicated in the evaluation of the emotional meaning of incoming stimuli. It is thought to integrate internal representations of the external world in the form of memory images with emotional experiences associated with those memories (Calvin). In a series of experiments, J LeDoux utilized repeated electrical stimulation of the amygdala to produce conditioned fear responses. He found that cortical lesions prevent their extinction. This led him to conclude that, once formed, the subcortical traces of the conditioned fear response are indelible, and that "emotional memory may be forever". Paul filmed us for approximately eight years. First using the Super 8 format and later straight onto VHS using a cumbersome, oversized camera that fed into a VHS deck carried over the shoulder in a plastic satchel. Zimmerman suggests that home movies graph the contradictions between the realities of family life bounded by class, race, and gender expectations and the fantasies of the nuclear family, and they also reveal the unfinished production of obedient subjects and histories (278). They create expectations that wrestle with the fragile nature of family. Paul wasn’t the only “cinematographer” in the family. The camera was often passed to Inez so that Paul’s presence in family occasions could be authenticated. Eventually both Brendan and myself were allowed moments of seeing the world through the black and white view finders. Perhaps those early cinematographic moments started me on the path to today. The picture as a model of reality. The “real” and the “performed” act is twofold in the home movie. Our many different roles exemplify the separation and interrelation of our public and private lives. The act of mimesis seems to signify “I exist” or, rather, “I represent myself here for immortality.” This imitation of ourselves is an authentic “copy” of the original, since actor and role are identical (Forgacs 52). Identical yet problematic: dissociated? Merilee Bennett’s 1987 film, A Song of Air, is a compilation film composed of home movies shot by Merilee’s father, Reverend Arnold Lucas Bennett, who regularly filmed his family with a Paillard Bolex 16mm camera between 1956 and 1983. I saw A Song of Air as an undergraduate and it has never left me. It did not occur to me until years later to work with my own family’s filmic archive but Bennett’s work is undoubtedly a key influence. The film invites two levels of reading: first, the level of the home movies made by the father; second, the analysis made by Merilee of her father’s home movies through her own reediting of the images and her omnipresent commentary in the form of a letter addressed to her father (Odin 256).No other types of films evidence as much direct address as the home movie. The family filmmaker’s camera functions first as a go-between and only secondly as a recording instrument. To film is to take part in a collective game in the family domain. These familial interactions are not always peaceful. In a personal letter, Merilee Bennett recounts one of these conflicts. “The shot of him [my father] talking directly into the camera with a tree and blue sky behind him was shot by me when I was 12 years old and he is actually telling me to stop, that it was enough now. I remember holding my finger on that button knowing that he couldn’t get really mad at me because I would have it on film, so he had to keep smiling even though he was getting cross.” Merilee reclaims her identity through editing, imposing her own order on her father’s films. The father, “like an omnipotent God,” uses cinema to mold his family.Paul Ewing may have been doing the same – he was the only one aware of how fractured the family, his family, our family, my family actually was.In her autobiography The Words to Say It, Marie Cardinal explains to her psychoanalyst that after clinical treatment she had the strength to undertake a search for the origin of her trauma. I had a similar experience in that I was encouraged by a therapist to ask my father about the reasons behind his infidelity and what he felt were the grounds for his divorce. I had for many years believed it was because of me, that I had disappointed him as a son. Cardinal remembered her father filmed her pissing in the forest. Conscious that her urination has not only been watched, but also filmed, she felt traumatized and thought, “I want to hurt him. I want to kill him! (151)” Shooting a home movie does not always have such dramatic consequences, but it always carries a risk for the subjects filmed, especially children. Parents are not aware of the psychic consequences of a seemingly harmless act. Paul Ewing filmed my brother and I in the bath. I was using the toilet as the filming started and jumped, laughing into the tub with my brother. There is nothing suspect in this description. As a father myself I can understand the desire to film all aspects of my child’s life. At last count I have approximately thirty thousand digital photos and videos of my five year old son and the numbers are rising for his one year old sister. As Paul films us, my brother and I, playing with action figures and acting up for the camera, I laugh at my father. Some days later we were assembled to watch Paul’s latest film. The family convened in the living room, along with our maid Yolanda. When the image came on screen, it seemed to slow down. All I saw was my bottom and then as I entered the bath, my penis. And I saw it being seen by Yolanda. I was devastated, ashamed and furious at my father for showing this private moment. I ran off in tears.Unlike traditional cinematographic projection, to watch a home movie is to be involved in a “performance.” Boris Eikhenbaum proposed the notion of “interior language”: “The process of interior discourse resides in the mind of the spectator.” This interior language can be understood without referring to a context because it is located in the Subject. With the home movie, the context resides in the experience of the Subject. This model explains how completely banal images can refer to representations far removed from what is represented. Contrary to the generally euphoric collective experience, this process of returning to the self often conjures painful memories. One image, of Inez, my mother, comes up in my mind a lot. She stares into the camera as my Father films her. She appears to be engaged in a non verbal conversation with him, with the camera. She doesn’t smile but looks ready to resign, the request to stop filming that is present in so many other instances of her in Paul’s films is absent – it seems to suggest there is no point in her asking. Shortly after the date stamped onto the video image, she revealed to my brother and myself that Paul had been having an affair. “Your father does not love us anymore”. In therapy I have explored both moments – the memory and the video taped image. Something in my mother’s gaze suggests the break, the end of the illusion Paul had crafted both on film and video, and in life. Pierre Bourdieu, discussing family photography, argued that nothing could be filmed outside of what must be filmed. The same ritual ceremonies (marriage, birth, family meals, gift-giving), the same daily scenes (a baby in his mother’s arms, a baby having a bath), the same vacation sequences (playtime on the beach, walks in the forest) appear across most home movies. Discussing “common things,” Georges Perec contended the difficulty is “to free these images from the straitjacket in which they are trapped, to make them produce meaning and speak about what they are and what we are.” Home movies are precisely “common things.” Erving Goffman terms the process of “shifting of frame.” A film of minor importance can suddenly become a fabulous document when the historical context of reading changes. Every old home movie that operates within a different spatial, cultural, ethnic, or social framework will benefit from de-framed readings. Even if these images were not documents and were stereotypical home movies, they become precious because they look new. Hungarian filmmaker Péter Forgács “creates masterful reflections on the notion of the document itself: why one makes films; the language of the images and language itself; and the possibilities that the image holds for cognition” (Odin 266). The cinematography of Paul Ewing remains a source of possibilities. ReferencesAnderson, Steve F. Technologies of History: Visual Media and the Eccentricity of the Past. Lebanon, NH: University Press of New England, 2011.Bourdieu, Pierre. Photography: A Middle-Brow Art. Cambridge: Polity, 1990Boylorn, Robin M., and Mark P. Orbe, eds. Critical Autoethnography: Intersecting Cultural Identities in Everyday Life. Walnut Creek, CA: Left Coast Press, 2013.Calvin, WH. The Cerebral Symphony. New York: Bantam, 1990.Cardinal, Marie. The Words to Say It: An Autobiographical Novel. London: Women's Press, 1993.Denzin, NK. Interpretive Ethnography: Ethnographic Practices for the 21st Century. Thousand Oaks, CA: Sage, 1997.Ellis, C. The Ethnographic I: A Methodological Novel about Autoethnography. Walnut Creek, CA: AltaMira Press, 2004. Eikhenbaum, Boris. “Problemes de Cine-Stylistique.” Cahiers du Cinema 220-221 (1970): 70-78.Forgacs, Peter. “Wittgenstein Tractatus: Personal Reflections of Home Movies.” Mining the Home Movie: Excavations in Histories and Memories. Berkeley. Eds. Karen Ishizuka and Patricia Zimmermann. Berkeley, CA: University of California Press, 2007. 47-56.Goffman, Erving. Frame Analysis: An Essay on the Organization of Experience. Cambridge, MA: Harvard University Press, 1974.Ishizuka, Karen L. “The Home Movie: A Veil of Poetry.” Jubilee Book: Essays on Amateur Film (1997): 45-50.Janet, P. L’Automatisme Psychologique. Paris: Alcan, 1889. Janet, P. Les Medications Psychologiques. Paris: Alcan, 1925. MacLean, PD. “Brain Evolution Relating to Family, Play, and the Separation Call.” Arch Gen Psychiat 42 (1985): 505-517.Odin, Roger. “Reflections on the Family Home Movie as Document: A Semio-Pragmatic Approach.” Mining the Home Movie: Excavations in Histories and Memories. Eds. Karen Ishizuka and Patricia Zimmermann. Berkeley, CA: University of California Press, 2007. 255-271.Perec, Georges. “Approche de Quoi.” Le Pourrissement des Societies. 1975. 251-255.Piaget, Jean. Play, Dreams and Imitation in Childhood. Florence: Routledge, 2013.Schachtel, Ernest G. Metamorphosis: On the Development of Affect, Perception, Attention, and Memory. New York: Basic Books, 1959.Van der Kolk, Bessel. The Body Keeps the Score: Memory and the Evolving Psychobiology of Post Traumatic Stress. Boston: Harvard Medical School, 1994.Van der Kolk, Bessel, and Rita Fisler. “Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study.” Journal of Traumatic Stress (1995): 505-525.Wittgenstein, Ludwig. Culture and Value. University of Chicago Press, 1984.Zimmerman, Patricia. “Morphing History into Histories: From Amateur Film to the Archive of the Future.” Mining the Home Movie: Excavations in Histories and Memories. Eds. Karen Ishizuka and Patricia Zimmermann. Berkeley, CA: University of California Press, 2007. 275-288.

Lars von Trier’s film Melancholia depicts the last days of the earth through the eyes of a young woman, Justine, who is suffering from a severe depressive illness. In the hours leading up to the Earth’s destruction through the impact of a massive blue planet named Melancholia, Justine tells her sister that “the Earth is evil, we don’t need to grieve for it. Nobody will miss it.” We can read this apparently anti-environmental statement in one sense as a symptom of Justine’s melancholic depression. The Diagnostic and Statistical Manual of Mental Disorders defines melancholia as a form of depression that is “qualitatively different from the sadness experienced during bereavement” (419). It is as if Justine’s illness relates to some ungrievable loss, a loss so pathologically far reaching that it short circuits the normal psychology of mourning. But, in another sense, does her statement not strike us with the ring of an absolute and inescapable truth? In the wake of our destruction, there would be no one left to mourn it since human memory itself would have been destroyed along with the global ecosystems which support and sustain it. The film’s central dramatic metaphor is that the experience of a severe depressive episode is like the destruction of the world. But the metaphor can be turned around to suggest that ecological crisis, real irreparable damage to the environment to the point where it may no longer be able to support human life, affects us with a collective melancholia because the destruction of the human species is a strictly ungrievable event. The discoveries of Charles Darwin in the nineteenth century constituted a major thought event which placed the emergence of humanity within a temporal context extending far beyond the limits of human memory. Claire Colebrook suggests that the equivalent event for present times is the thought of our own extinction, the awareness that environmental changes could bring about the end of the species: “[the] extinction awareness that is coming to the fore in the twenty-first century adds the sense of an ending to the broader awareness of the historical emergence of the human species.” While the scientific data is stark, our mediated cultural experience provides us with plenty of opportunities to, in Colebrook’s words, “[domesticate] the sense of the human end” by affirming “various modes of ‘post-humanism’” in ways which ultimately deny the shattering truth of extinction. This domestication obviously takes place in one sense on the level of a conscious denial of the scale of the ecological crisis. On another level, however, environmentally conscious representations of “the planet” or “nature” as a sheer autonomous objectivity, a self-contained but endangered natural order, may ultimately be the greatest obstacle to genuine ecological thinking. By invoking the concept of a non-human nature in perfect balance with itself we factor ourselves out of the ecological equation while simultaneously drawing on the power of an objectifying gaze. Slavoj Žižek gives the example of Alan Weisman’s book The World Without Us which imagines a contemporary world in which all humans have disappeared and nature reasserts itself in the ruins of our abandoned cities. Žižek describes this as the ultimate expression of ideology because: we, the humans, are here reduced to a pure disembodied gaze observing our own absence [...] this is the fundamental subjective position of fantasy: to be reduced to a gaze observing the world in the condition of the subject’s non-existence—like the fantasy of witnessing the act of one’s own conception, parental copulation, or the act of witnessing one’s own burial (80). In many ways, the very spectacle or fantasy of our own destruction has provided us with a powerful means of naturalising it—environmental catastrophe occurs to and in a “nature” whose essence excludes us—and this renders it compatible with a psychology by which the human end is itself internalised, processed, and normalised. Ironically, this normalisation may have been affected to a great extent through the popularisation, over the last ten years or so, of environmental discourses relating to the grave threats of climate change. A film such as Wall-E, for example, shows us an entirely depopulated, desertified world in which the eponymous robot character sorts through the trash of human history, living an almost-human life among the ruins. The robot functions as a kind of proxy humanity, placing us, the viewers, in a position posterior to our own species extinction and thus sending us the ultimately reassuring message that, even in our absence, our absence will be noted. In a similar way, the drama-documentary The Age of Stupid presents a future world devastated by environmental collapse in which a lone archivist presides over the whole digitised memory of humanity and carefully constructs out of actual news and documentary footage the story of our demise. These narratives and others like them ultimately serve, whatever their intentions, to domesticate the end of humanity through the logic of a post-human mastery of the story of our own obliteration. The starker truth with which Melancholia confronts us is that the end of humanity cannot and will not be internalised by any process of human memorialisation. Von Trier’s film does not portray any post-catastrophe world from which we might be able to extract a degree of psychological comfort or residual sense of mastery. Rather, the narrative frame is entirely bounded by the impact event, which we witness first in the film’s opening shots and then again at its close. There is no narrative time posterior to the impact and yet for us, the viewers, everything happens in its shattering aftermath, according to the strange non-successional logic of the future-anterior. Everything begins and ends with the moment of impact. If the narrative itself is concerned with the lives of the characters, particularly the effects of the main character’s depression on her family relationships, then the film’s central event remains radically disjunctive, incapable of being processed on this interpersonal level through the standard cinematic tropes of the disaster or survival genres. The value of regarding Melancholia as an environmental film, then, is that it profoundly de-psychologises the prospect of our extinction while forcing the burden of this event’s unfathomable content onto us. Von Trier’s film suggests that melancholy, not mourning, is a more apt emotional register for ecological crisis and for the extinction awareness it brings, and in this sense Melancholia represents a valuable alternative to more standard environmental narratives which remain susceptible to ideological reinscriptions of human (or post-human) mastery. As ecocritic Timothy Morton suggests, “melancholy is more apt, even more ethically appropriate, to an ecological situation in which the worst has already happened, and in which we find ourselves [...] already fully implicated” (75–6). The most influential account of mourning and melancholia comes from Sigmund Freud, who described these attitudes as two different ways of dealing with loss. In the process of mourning, Freud states that there comes the realisation “that the loved object no longer exists” which “[demands] that all libido shall be withdrawn from its attachments to that object” (245). The healthy outcome of this very painful process is that our libidinal attachments are free once again to take on another object of love; the lost object can be replaced according to a logic of temporal succession. Melancholia also results from a loss, says Freud, but this time it relates not simply or primarily to a replaceable external object but, more complexly, to something in the ego itself, not a discrete thing in the world but a certain way of being in the world which the lost object facilitated. Freud writes that the trauma of melancholia is thus manifested by the ego itself taking on or embodying the loss. The ego, stripped of its sense of being, comes to mimic the non-existence of that which once supported it. The “delusion” of the melancholic’s depressive state, says Freud, stems from the fact that something has ruptured her affective and libidinal attachment to the world, but this cannot be psychologically processed in terms of a replaceable loss since what is lost was never simply an external object. Her world is struck by an absence that cannot be mourned because it is kept alive as a non-being which she is. She has taken on the burden of this structural impossibility and does not pursue an imaginary resolution of it which, to invoke Žižek’s Lacanian terms once more, would involve her submitting to the subjective position of fantasy (i.e. becoming a witness to her own non-existence). The melancholic’s attitude is, Freud observes, “psychologically very remarkable” because it involves “an overcoming of the instinct which compels every living thing to cling to life” (246). The melancholic carves out an existence apparently contrary to nature. This is the context in which Justine remarks that the earth, as an ungrievable object, is “evil.” Her melancholia is never explained in the course of the film, and, indeed, we see little of her personality apart from the events which manifest her psychological crisis. The film opens with the moment of interplanetary impact itself. The great blue planet of Melancholia approaches and begins to swallow the earth into its atmosphere. We cut immediately to Justine and her sister in the moments just before the impact: the air is electrified by the approaching collision and birds cascade from the trees. Our way into the narrative is this moment of chaos and dispersion, but von Trier’s depiction of it, his use of highly choreographed slow-motion shots resembling tableaux vivants, distance us from any sense of urgency or immediacy. It is as if the closer we come to the collision, the less real and the more stylised the world becomes; as if the impact holds a content which cannot be rendered in realist terms. By contrast, the subsequent scenes focusing on Justine’s interpersonal drama use a shaky, handheld camera which embeds us in the action. The narrative follows Justine on her wedding day. As events unfold we see cracks appear in the wedding party’s luxurious facade: Justine’s divorced parents argue viciously; her wealthy brother-in-law, who funded the wedding, fears that the occasion may be ruined by petty squabbling, to his great expense. Beneath these cracks, however, we realise that there is a deeper, more inexplicable crack opening up within Justine herself. At one point she retreats with her newlywed husband from the tumult of the wedding party. We expect from this scene an articulation or partial resolution, perhaps, of Justine’s mental conflict, or at least an insight into her character. In a more conventional story, this moment of conjugal intimacy would allow Justine to express an “authentic” desire, distinct from the superficial squabbling of her family, a means to “be herself.” But this doesn’t happen. Justine inexplicably rejects her husband’s overtures. In clinical terms, we might say that Justine’s behaviour corresponds to “anhedonia,” a loss of interest in the normal sources of pleasure or enjoyment. Invoking Freud, we could add to this that the very objective viability of her libidinal attachments has been called into question and that this is what precipitates her crisis. If such attachments are what ground us in reality, Justine’s desire seems to have become ungrounded through the emergence of something “nonobjectifiable,” to borrow a term from philosophers Deleuze and Guattari (What is Philosophy?, 209). This “something” is revealed only in the second half of the film with the appearance of Melancholia and the prospect of its obliterating impact. Justine is drawn to this new planet, in one scene luxuriating naked beneath its blue glow. We could argue, in one sense, that she has discovered in Melancholia a correlate to her own self-destructive desire: the only thing that can possibly gratify her is the annihilation of the earth itself. However in another, more constructive sense, we can say that her melancholic desire amounts to a kind of geophilosophical critique, a political and ultimately ecological protest against the territorialisation of her desire according to a supposed acceptability of objects. Deleuze and Guattari suggest that, if desire’s libidinal attachments form a kind of ground or “territory” then all territories interact with one another at some level because they are all equally founded on “lines of deterritorialization” sweeping them towards a mutually shared, extra-territorial outside (A Thousand Plateaus, 9). Or, putting it in plainer terms: beneath every ground is a non-ground such that the earth cannot ultimately ground itself in itself. Every mental, material, or social territory is founded upon this global movement of ungrounding. The trauma of Justine’s melancholia refers us to something which cannot be resolved within the given territories of her social or interpersonal milieus. While her illness can be registered in terms of the events of the film’s narrative time, the film’s central event—the collision with Melancholia—remains irreducible to the memorial properties of storytelling. We may thus argue that the impact event is not strictly speaking an element of the film’s narrative, but rather a pure cinematic sign evoking a radical form of ecological openness. The film moves through different territories—conjugal, familial, economic, scientific—but what propels us from one territory to another is the impact event whose content is reducible to none of these territories. Of all the film’s characters, only Justine is “open” to this absolute irreducibility, this resistance to closure. Her openness to Melancholia is not determined by whether or not it can be objectified, that is, rendered assimilable to the terms of a given territory. Both her brother-in-law (an amateur astronomer) and her sister attempt to calculate the chances of impact, but Justine remains open to it in a manner which does not close off that which precludes survival. In the end, as Melancholia bears down on the Earth, Justine’s attitude—which in Freud’s terms is antithetical to the instinct for life—turns out to be the most appropriate one. The point of this article is certainly not to argue that we should acquiesce to the traumatic realities of environmental crisis. Its aim, rather, is to suggest that well-being and harmony may no longer describe the appropriate emotional register for ecological thinking, given the current urgency of the crisis. Human and ecological health may, after all, be radically different and incommensurable things. The great anthropologist and structuralist thinker Claude Lévi-Strauss once remarked: I am concerned with the well-being of plants and animals that are threatened by humanity. I think ecologists make the mistake of thinking that they can defend humans and nature at the same time. I think it is necessary to decide if one prefers humans or nature. I am on the side of nature (qtd in Conley, 66). Lévi-Strauss may well be right when he says that a common human and ecological health may be an illusion of wishful thinking. However, what if there is a common trauma, whose ineradicability would not be a tragedy but, rather, evidence of radical openness in which we no longer have to pick sides (humans or plants and animals)? What if the proper “base” from which to begin thinking ecologically were not a conception of a harmonious human-ecological whole but a foundational non-harmony, an encounter with which contains something ineliminably traumatising? In a recent paper, the philosopher Reza Negarestani proposes just such a traumatic account of ecological openness. All existence, understood geophilosophically, is, says Negarestani, “conditioned by a concatenation of traumas or cuts [...] there is no single or isolated psychic trauma [...] there is no psychic trauma without an organic trauma and no organic trauma without a terrestrial trauma that in turn is deepened into open cosmic vistas.” Ecological openness, in this sense, would be necessarily melancholic, in the terms described above, in that it would necessitate the perpetual precariousness of those links by which we seek to ground ourselves. Ecology is all too often given to a “mournful” attitude, which is, as we’ve argued, the very attitude of psychological incorporation, healing, and normalisation. Similarly, “nature,” we are told, holds the key to harmonious self-regulation. But what if today such notions are obstacles to a genuine awareness of the ecological realities facing us all (humans and non-humans)? What if this ideal of nature were just a product of our own desire for stability, order, and regularity—for some imaginary extra-social and non-human point of reference by which to attain to a position of mastery in the telling of the story of ourselves? References Age of Stupid, The. Dir. Fanny Armstrong. Spanner Films, 2009. American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Text Revision. Washington: American Psychological Association, 2000. Colebrook, Claire. “Introduction: Framing the End of the Species.”.Extinction. Ed. Claire Colebrook. Open Humanities Press. 2012. 14 April 2012. Conley, Vera Andermatt. Ecopolitics: The Environment in Poststructuralist Thought. London: Routledge, 1997. Deleuze, Gilles, and Felix Guattari. A Thousand Plateaus: Capitalism and Schizophrenia. Trans. Brian Massumi. Minneapolis: University of Minnesota Press, 1987. Deleuze, Gilles and Felix Guattari. What is Philosophy? Trans. Hugh Tomlinson and Graham Burchell. New York: Columbia UP, 1994. Freud, Sigmund. “Mourning and Melancholia.” The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 24. Ed. and trans. James Strachey. London: Hogarth Press, 1917. 237–58. Melancholia. Dir. Lars von Trier. Zontropa, 2011. Morton, Timothy. Ecology Without Nature: Rethinking Environmental Aesthetics. Cambridge: Harvard University Press, 2007. Negarestani, Reza. “On the Revolutionary Earth: A Dialectic in Territopic Materialism.” Dark Materialism Conference. Natural History Museum, London. January 12th 2011. Weisman, Alan. The World Without Us. New York: Picador, 2007. WALL-E. Dir. Andrew Stanton. Pixar, 2008. Žižek, Slavoj. Living in the End Times. London: Verso, 2010.

Abstract Background Evidence suggests wide variability in the provision of mental healthcare across countries. Countries experiencing fragility related risks suffer from a high burden of mental-ill health and additionally have limited capacity to scale up mental health services given financial and human resource shortages. Integration of mental health services into routine primary care is one potential strategy for enhancing service availability, however little is known about the experiences of currently active health care providers involved in mental health and psychosocial support service (MHPSS) provision at primary care level. This study aims to determine how healthcare providers offering MHPSS services at primary care levels in Lebanon perceive mental health and the health system’s ability to address the rising mental ill-health burden with a view to identify opportunities for strengthening MHPSS service implementation geared towards integrated person focused care model. Methods A qualitative study design was adopted including 15 semi-structured interviews and 2 participatory group model-building workshops with health care providers (HCPs) involved in mental healthcare delivery at primary care level. Participants were recruited from two contrasting fragility contexts (Beirut and Beqaa). During workshops, causal loop diagrams depicting shared understandings of factors leading to stress and mental ill health, associated health seeking behaviors, and challenges and barriers within the health system were elicited. This research is part of a larger study focused on understanding the dynamics shaping mental health perceptions and health seeking behaviours among community members residing in Lebanon. Results Findings are organized around a causal loop diagram depicting three central dynamics as described by workshop participants. First, participants linked financial constraints at household levels and the inability to secure one’s livelihood with contextual socio-political stressors, principally referring to integration challenges between host communities and Syrian refugees. In a second dynamic, participants linked exposure to war, conflict and displacement to the occurrence of traumatic events and high levels of distress as well as tense family and community relations. Finally, participants described a third dynamic linking cultural norms and patriarchal systems to exposure to violence and intergenerational trauma among Lebanon’s populations. When describing help-seeking pathways, participants noted the strong influence of social stigma within both the community and among health professionals; the latter was noted to negatively affect patient-provider relationships. Participants additionally spoke of difficulties in the delivery of mental health services and linked this to the design of the health system itself, noting the current system being geared towards patient centered care, which focuses on the patient’s experiences with a disease only, rather than person focused care where providers and patients acknowledge broader structural and social influences on health and work together to reach appropriate decisions for tackling health and other social needs. Barriers to delivery of person focused care include the lack of coherent mental health information systems, limited human capacity to deliver MHPSS services among primary health care staff and inadequate service integration and coordination among the many providers of mental health services in our study contexts. Critically however, provider accounts demonstrate readiness and willingness of health professionals to engage with integrated person focused care models of care. Conclusions Mental ill health is a major public health problem with implications for individual health and wellbeing; in a fragile context such as Lebanon, the burden of mental ill health is expected to rise and this presents substantive challenges for the existing health system. Concrete multi-sectoral efforts and investments are required to (1) reduce stigma and improve public perceptions surrounding mental ill health and associated needs for care seeking and (2) promote the implementation of integrated person focused care for addressing mental health.

In a media saturated world, doodles have recently received the kind of attention usually reserved for coverage of racy extra marital affairs, corrupt governance, and product malfunction. Former British Prime Minister Blair’s private doodling at a World Economic Forum meeting in 2005 raised suspicions that he, according to one keen graphologist, struggled “to maintain control in a confusing world," which infers he was attempting to cohere a scattershot, fragmentary series of events (Spiegel). However, placid-faced Microsoft CEO Bill Gates, who sat nearby, actually scrawled the doodles. In this case, perhaps the scrawls mimicked the ambience in the room: Gates might have been ‘tuning’–registering the ‘white noise’ of the participants, letting his unconscious dictate doodles as a way to cope with the dissonance trekking in with the officialspeak. The doodles may have documented and registered the space between words, acting like deposits from his gestalt.Sometimes the most intriguing doodles co-exist with printed texts. This includes common vernacular graffiti that lines public and private books and magazines. Such graffiti exposes tensions in the role of readers as well as horror vacui: a fear of unused, empty space. Yet, school children fingering fresh pages and stiff book spines for the first few times often consider their book pages as sanctioned, discreet, and inviolable. The book is an object of financial and cultural investment, or imbued both with mystique and ideologies. Yet, in the e-book era, the old-fashioned, physical page is a relic of sorts, a holdover from coarse papyrus culled from wetland sage, linking us to the First Dynasty in Egypt. Some might consider the page as a vessel for typography, a mere framing device for text. The margins may reflect a perimeter of nothingness, an invisible borderland that doodles render visible by inhabiting them. Perhaps the margins are a bare landscape, like unmarred flat sand in a black and white panchromatic photo with unique tonal signature and distinct grain. Perhaps the margins are a mute locality, a space where words have evaporated, or a yet-to-be-explored environment, or an ambient field. Then comes the doodle, an icon of vernacular art.As a modern folklorist, I have studied and explored vernacular art at length, especially forms that may challenge and fissure aesthetic, cultural, and social mores, even within my own field. For instance, I contend that Grandma Prisbrey’s “Bottle Village,” featuring millions of artfully arranged pencils, bottles, and dolls culled from dumps in Southern California, is a syncretic culturescape with underlying feminist symbolism, not merely the product of trauma and hoarding (Ensminger). Recently, I flew to Oregon to deliver a paper on Mexican-American gravesite traditions. In a quest for increased multicultural tolerance, I argued that inexpensive dimestore objects left on Catholic immigrant graves do not represent a messy landscape of trinkets but unique spiritual environments with links to customs 3,000 years old. For me, doodles represent a variation on graffiti-style art with cultural antecedents stretching back throughout history, ranging from ancient scrawls on Greek ruins to contemporary park benches (with chiseled names, dates, and symbols), public bathroom latrinalia, and spray can aerosol art, including ‘bombing’ and ‘tagging’ hailed as “Spectacular Vernaculars” by Russell Potter (1995). Noted folklorist Alan Dundes mused on the meaning of latrinalia in Here I Sit – A Study of American Latrinalia (1966), which has inspired pop culture books and web pages for the preservation and discussion of such art (see for instance, www.itsallinthehead.com/gallery1.html). Older texts such as Classic American Graffiti by Allen Walker Read (1935), originally intended for “students of linguistics, folk-lore, abnormal psychology,” reveal the field’s longstanding interest in marginal, crude, and profane graffiti.Yet, to my knowledge, a monograph on doodles has yet to be published by a folklorist, perhaps because the art form is reconsidered too idiosyncratic, too private, the difference between jots and doodles too blurry for a taxonomy and not the domain of identifiable folk groups. In addition, the doodles in texts often remain hidden until single readers encounter them. No broad public interaction is likely, unless a library text circulates freely, which may not occur after doodles are discovered. In essence, the books become tainted, infected goods. Whereas latrinalia speaks openly and irreverently, doodles feature a different scale and audience.Doodles in texts may represent a kind of speaking from the ‘margin’s margins,’ revealing the reader-cum-writer’s idiosyncratic, self-meaningful, and stylised hieroglyphics from the ambient margins of one’s consciousness set forth in the ambient margins of the page. The original page itself is an ambient territory that allows the meaning of the text to take effect. When those liminal spaces (both between and betwixt, in which the rules of page format, design, style, and typography are abandoned) are altered by the presence of doodles, the formerly blank, surplus, and soft spaces of the page offer messages coterminous with the text, often allowing readers to speak, however haphazardly and unconsciously, with and against the triggering text. The bleached whiteness can become a crowded milieu in the hands of a reader re-scripting the ambient territory. If the book is borrowed, then the margins are also an intimate negotiation with shared or public space. The cryptic residue of the doodler now resides, waiting, for the city of eyes.Throughout history, both admired artists and Presidents regularly doodled. Famed Italian Renaissance painter Filippo Lippi avoided strenuous studying by doodling in his books (Van Cleave 44). Both sides of the American political spectrum have produced plentiful inky depictions as well: roughshod Democratic President Johnson drew flags and pagodas; former Hollywood fantasy fulfiller turned politician Republican President Reagan’s specialty was western themes, recalling tropes both from his actor period and his duration acting as President; meanwhile, former law student turned current President, Barack Obama, has sketched members of Congress and the Senate for charity auctions. These doodles are rich fodder for both psychologists and cross-discipline analysts that propose theories regarding the automatic writing and self-styled miniature pictures of civic leaders. Doodles allow graphologists to navigate and determine the internal, cognitive fabric of the maker. To critics, they exist as mere trifles and offer nothing more than an iota of insight; doodles are not uncanny offerings from the recesses of memory, like bite-sized Rorschach tests, but simply sloppy scrawls of the bored.Ambient music theory may shed some light. Timothy Morton argues that Brian Eno designed to make music that evoked “space whose quality had become minimally significant” and “deconstruct the opposition … between figure and ground.” In fact, doodles may yield the same attributes as well. After a doodle is inserted into texts, the typography loses its primacy. There is a merging of the horizons. The text of the author can conflate with the text of the reader in an uneasy dance of meaning: the page becomes an interface revealing a landscape of signs and symbols with multiple intelligences–one manufactured and condoned, the other vernacular and unsanctioned. A fixed end or beginning between the two no longer exists. The ambient space allows potential energies to hover at the edge, ready to illustrate a tension zone and occupy the page. The blank spaces keep inviting responses. An emergent discourse is always in waiting, always threatening to overspill the text’s intended meaning. In fact, the doodles may carry more weight than the intended text: the hierarchy between authorship and readership may topple.Resistant reading may take shape during these bouts. The doodle is an invasion and signals the geography of disruption, even when innocuous. It is a leveling tool. As doodlers place it alongside official discourse, they move away from positions of passivity, being mere consumers, and claim their own autonomy and agency. The space becomes co-determinant as boundaries are blurred. The destiny of the original text’s meaning is deferred. The habitus of the reader becomes embodied in the scrawl, and the next reader must negotiate and navigate the cultural capital of this new author. As such, the doodle constitutes an alternative authority and economy of meaning within the text.Recent studies indicate doodling, often regarded as behavior that announces a person’s boredom and withdrawal, is actually a very special tool to prevent memory loss. Jackie Andrade, an expert from the School of Psychology at the University of Plymouth, maintains that doodling actually “offsets the effects of selective memory blockade,” which yields a surprising result (quoted in “Doodling Gets”). Doodlers exhibit 29% more memory recall than those who passively listen, frozen in an unequal bond with the speaker/lecturer. Students that doodle actually retain more information and are likely more productive due to their active listening. They adeptly absorb information while students who stare patiently or daydream falter.Furthermore, in a 2006 paper, Andrew Kear argues that “doodling is a way in which students, consciously or not, stake a claim of personal agency and challenge some the values inherent in the education system” (2). As a teacher concerned with the engagement of students, he asked for three classes to submit their doodles. Letting them submit any two-dimensional graphic or text made during a class (even if made from body fluid), he soon discovered examples of “acts of resistance” in “student-initiated effort[s] to carve out a sense of place within the educational institution” (6). Not simply an ennui-prone teenager or a proto-surrealist trying to render some automatic writing from the fringes of cognition, a student doodling may represent contested space both in terms of the page itself and the ambience of the environment. The doodle indicates tension, and according to Kear, reflects students reclaiming “their own self-recognized voice” (6).In a widely referenced 1966 article (known as the “doodle” article) intended to describe the paragraph organisational styles of different cultures, Robert Kaplan used five doodles to investigate a writer’s thought patterns, which are rooted in cultural values. Now considered rather problematic by some critics after being adopted by educators for teacher-training materials, Kaplan’s doodles-as-models suggest, “English speakers develop their ideas in a linear, hierarchal fashion and ‘Orientals’ in a non-liner, spiral fashion…” (Severino 45). In turn, when used as pedagogical tools, these graphics, intentionally or not, may lead an “ethnocentric, assimilationist stance” (45). In this case, doodles likely shape the discourse of English as Second Language instruction. Doodles also represent a unique kind of “finger trace,” not unlike prints from the tips of a person’s fingers and snowflakes. Such symbol systems might be used for “a means of lightweight authentication,” according to Christopher Varenhorst of MIT (1). Doodles, he posits, can be used as “passdoodles"–a means by which a program can “quickly identify users.” They are singular expressions that are quirky and hard to duplicate; thus, doodles could serve as substitute methods of verifying people who desire devices that can safeguard their privacy without users having to rely on an ever-increasing number of passwords. Doodles may represent one such key. For many years, psychologists and psychiatrists have used doodles as therapeutic tools in their treatment of children that have endured hardship, ailments, and assault. They may indicate conditions, explain various symptoms and pathologies, and reveal patterns that otherwise may go unnoticed. For instance, doodles may “reflect a specific physical illness and point to family stress, accidents, difficult sibling relationships, and trauma” (Lowe 307). Lowe reports that children who create a doodle featuring their own caricature on the far side of the page, distant from an image of parent figures on the same page, may be experiencing detachment, while the portrayal of a father figure with “jagged teeth” may indicate a menace. What may be difficult to investigate in a doctor’s office conversation or clinical overview may, in fact, be gleaned from “the evaluation of a child’s spontaneous doodle” (307). So, if children are suffering physically or psychologically and unable to express themselves in a fully conscious and articulate way, doodles may reveal their “self-concept” and how they feel about their bodies; therefore, such creative and descriptive inroads are important diagnostic tools (307). Austrian born researcher Erich Guttman and his cohort Walter MacLay both pioneered art therapy in England during the mid-twentieth century. They posited doodles might offer some insight into the condition of schizophrenics. Guttman was intrigued by both the paintings associated with the Surrealist movement and the pioneering, much-debated work of Sigmund Freud too. Although Guttman mostly studied professionally trained artists who suffered from delusions and other conditions, he also collected a variety of art from patients, including those undergoing mescaline therapy, which alters a person’s consciousness. In a stroke of luck, they were able to convince a newspaper editor at the Evening Standard to provide them over 9,000 doodles that were provided by readers for a contest, each coded with the person’s name, age, and occupation. This invaluable data let the academicians compare the work of those hospitalised with the larger population. Their results, released in 1938, contain several key declarations and remain significant contributions to the field. Subsequently, Francis Reitman recounted them in his own book Psychotic Art: Doodles “release the censor of the conscious mind,” allowing a person to “relax, which to creative people was indispensable to production.”No appropriate descriptive terminology could be agreed upon.“Doodles are not communications,” for the meaning is only apparent when analysed individually.Doodles are “self-meaningful.” (37) Doodles, the authors also established, could be divided into this taxonomy: “stereotypy, ornamental details, movements, figures, faces and animals” or those “depicting scenes, medley, and mixtures” (37). The authors also noted that practitioners from the Jungian school of psychology often used “spontaneously produced drawings” that were quite “doodle-like in nature” in their own discussions (37). As a modern folklorist, I venture that doodles offer rich potential for our discipline as well. At this stage, I am offering a series of dictums, especially in regards to doodles that are commonly found adjacent to text in books and magazines, notebooks and journals, that may be expanded upon and investigated further. Doodles allow the reader to repopulate the text with ideogram-like expressions that are highly personalised, even inscrutable, like ambient sounds.Doodles re-purpose the text. The text no longer is unidirectional. The text becomes a point of convergence between writer and reader. The doodling allows for such a conversation, bilateral flow, or “talking back” to the text.Doodles reveal a secret language–informal codes that hearken back to the “lively, spontaneous, and charged with feeling” works of child art or naïve art that Victor Sanua discusses as being replaced in a child’s later years by art that is “stilted, formal, and conforming” (62).Doodling animates blank margins, the dead space of the text adjacent to the script, making such places ripe for spontaneous, fertile, and exploratory markings.Doodling reveals a democratic, participatory ethos. No text is too sacred, no narrative too inviolable. Anything can be reworked by the intimate graffiti of the reader. The authority of the book is not fixed; readers negotiate and form a second intelligence imprinted over the top of the original text, blurring modes of power.Doodles reveal liminal moments. Since the reader in unmonitored, he or she can express thoughts that may be considered marginal or taboo by the next reader. The original subject of the book itself does not restrict the reader. Thus, within the margins of the page, a brief suspension of boundaries and borders, authority and power, occurs. The reader hides in anonymity, free to reroute the meaning of the book. Doodling may convey a reader’s infantalism. Every book can become a picture book. This art can be the route returning a reader to the ambience of childhood.Doodling may constitute Illuminated/Painted Texts in reverse, commemorating the significance of the object in hitherto unexpected forms and revealing the reader’s codex. William Blake adorned his own poems by illuminating the skin/page that held his living verse; common readers may do so too, in naïve, nomadic, and primitive forms. Doodling demarcates tension zones, yielding social-historical insights into eras while offering psychological glimpses and displaying aesthetic values of readers-cum-writers.Doodling reveals margins as inter-zones, replete with psychogeography. While the typography is sanctioned, legitimate, normalised, and official discourse (“chartered” and “manacled,” to hijack lines from William Blake), the margins are a vernacular depository, a terminus, allowing readers a sense of agency and autonomy. The doodled page becomes a visible reminder and signifier: all pages are potentially “contested” spaces. Whereas graffiti often allows a writer to hide anonymously in the light in a city besieged by multiple conflicting texts, doodles allow a reader-cum-writer’s imprint to live in the cocoon of a formerly fossilised text, waiting for the light. Upon being opened, the book, now a chimera, truly breathes. Further exploration and analysis should likely consider several issues. What truly constitutes and shapes the role of agent and reader? Is the reader an agent all the time, or only when offering resistant readings through doodles? How is a doodler’s agency mediated by the author or the format of texts in forms that I have to map? Lastly, if, as I have argued, the ambient space allows potential energies to hover at the edge, ready to illustrate a tension zone and occupy the page, what occurs in the age of digital or e-books? Will these platforms signal an age of acquiescence to manufactured products or signal era of vernacular responses, somehow hitched to html code and PDF file infiltration? Will bytes totally replace type soon in the future, shaping unforeseen actions by doodlers? Attached Figures Figure One presents the intimate graffiti of my grandfather, found in the 1907 edition of his McGuffey’s Eclectic Spelling Book. The depiction is simple, even crude, revealing a figure found on the adjacent page to Lesson 248, “Of Characters Used in Punctuation,” which lists the perfunctory functions of commas, semicolons, periods, and so forth. This doodle may offset the routine, rote, and rather humdrum memorisation of such grammatical tools. The smiling figure may embody and signify joy on an otherwise machine-made bare page, a space where my grandfather illustrated his desires (to lighten a mood, to ease dissatisfaction?). Historians Joe Austin and Michael Willard examine how youth have been historically left without legitimate spaces in which to live out their autonomy outside of adult surveillance. For instance, graffiti often found on walls and trains may reflect a sad reality: young people are pushed to appropriate “nomadic, temporary, abandoned, illegal, or otherwise unwatched spaces within the landscape” (14). Indeed, book graffiti, like the graffiti found on surfaces throughout cities, may offer youth a sense of appropriation, authorship, agency, and autonomy: they take the page of the book, commit their writing or illustration to the page, discover some freedom, and feel temporarily independent even while they are young and disempowered. Figure Two depicts the doodles of experimental filmmaker Jim Fetterley (Animal Charm productions) during his tenure as a student at the Art Institute of Chicago in the early 1990s. His two doodles flank the text of “Lady Lazarus” by Sylvia Plath, regarded by most readers as an autobiographical poem that addresses her own suicide attempts. The story of Lazarus is grounded in the Biblical story of John Lazarus of Bethany, who was resurrected from the dead. The poem also alludes to the Holocaust (“Nazi Lampshades”), the folklore surrounding cats (“And like the cat I have nine times to die”), and impending omens of death (“eye pits “ … “sour breath”). The lower doodle seems to signify a motorised tank-like machine, replete with a furnace or engine compartment on top that bellows smoke. Such ominous images, saturated with potential cartoon-like violence, may link to the World War II references in the poem. Meanwhile, the upper doodle seems to be curiously insect-like, and Fetterley’s name can be found within the illustration, just like Plath’s poem is self-reflexive and addresses her own plight. Most viewers might find the image a bit more lighthearted than the poem, a caricature of something biomorphic and surreal, but not very lethal. Again, perhaps this is a counter-message to the weight of the poem, a way to balance the mood and tone, or it may well represent the larval-like apparition that haunts the very thoughts of Plath in the poem: the impending disease of her mind, as understood by the wary reader. References Austin, Joe, and Michael Willard. “Introduction: Angels of History, Demons of Culture.” Eds. Joe Austion and Michael Willard. Generations of Youth: Youth Cultures and History in Twentieth-Century America. New York: NYU Press, 1998. “Doodling Gets Its Due: Those Tiny Artworks May Aid Memory.” World Science 2 March 2009. 15 Jan. 2009 ‹http://www.world-science.net/othernews/090302_doodle›. Dundes, Alan. “Here I Sit – A Study of American Latrinalia.” Papers of the Kroeber Anthropological Society 34: 91-105. Ensminger, David. “All Bottle Up: Reinterpreting the Culturescape of Grandma Prisbey.” Adironack Review 9.3 (Fall 2008). ‹http://adirondackreview.homestead.com/ensminger2.html›. Kear, Andrew. “Drawings in the Margins: Doodling in Class an Act of Reclamation.” Graduate Student Conference. University of Toronto, 2006. ‹http://gradstudentconference.oise.utoronto.ca/documents/185/Drawing%20in%20the%20Margins.doc›. Lowe, Sheila R. The Complete Idiot’s Guide to Handwriting Analysis. New York: Alpha Books, 1999. Morton, Timothy. “‘Twinkle, Twinkle Little Star’ as an Ambient Poem; a Study of Dialectical Image; with Some Remarks on Coleridge and Wordsworth.” Romantic Circles Praxis Series (2001). 6 Jan. 2009 ‹http://www.rc.umd.edu/praxis/ecology/morton/morton.html›. Potter, Russell A. Spectacular Vernaculars: Hip Hop and the Politics of Postmodernism. Albany: State University of New York, 1995. Read, Allen Walker. Classic American Graffiti: Lexical Evidence from Folk Epigraphy in Western North America. Waukesha, Wisconsin: Maledicta Press, 1997. Reitman, Francis. Psychotic Art. London: Routledge, 1999. Sanua, Victor. “The World of Mystery and Wonder of the Schizophrenic Patient.” International Journal of Social Psychiatry 8 (1961): 62-65. Severino, Carol. “The ‘Doodles’ in Context: Qualifying Claims about Contrastive Rhetoric.” The Writing Center Journal 14.1 (Fall 1993): 44-62. Van Cleave, Claire. Master Drawings of the Italian Rennaissance. Cambridge, Mass.: Harvard UP, 2007. Varenhost, Christopher. Passdoodles: A Lightweight Authentication Method. Research Science Institute. Cambridge, Mass.: Massachusetts Institute of Technology, 2004.

Contemporary definitions of resilience stress adaptability to changing ecological and economic conditions (Berkes, Colding and Folke; Castleden, McKee, Murray and Leonard 369). But this approach to resilience is a measure of individual ‘fitness’ to an adaptive whole (Hughes 165; McMahon et al.; Walker and Cooper). Not only is this incongruous with the experience of reproductive loss and infertility, it also works to sideline alternative forms or sources of resilience (Cox). In this paper, we share our efforts to build on previous theories of resilience by engaging in intimate dialogues and written reflections about our personal experiences with reproductive loss. Throughout the paper our reflections are interspersed with our ‘findings’ about the relationship between reproduction and resilience. For us, an active process of dialogically grounded reflection opened up the possibility of a different type of theoretical engagement, one that ultimately produced different enactments, and offered unexpected redirections, both of our experience with reproductive resilience, and in the resilience literature at large. This deeply personal, dialogical frame allowed us to move beyond the anecdotal and confessional to encompass a praxis that engaged the acutely affective reality of reproductive resiliency. Katherine: Three years ago, in the wake of the global financial crisis, I became interested in growing references to resilience in the media. I decided to start a graduate reading group on this theme. This was 'serious academic work.' We looked at questions like: Why has the UNDP rebranded itself 'Empowered Lives, Resilient Nations'? But my thinking about resilience was interrupted by a personal crisis. In January 2011, I was surprised and delighted to discover I was pregnant after years of clinically diagnosed 'unexplained infertility.' So my husband and I were devastated when, in May, a medical crisis (for me, not the baby) forced us to abort the pregnancy in its fifth month. Two years of exhausting medical interventions later, I learned that I am unable to bear children of my own—unable to reproduce—a fact which I am still actively struggling to reconcile. Ayumi: Strange the surprising state of affairs that would shift an employer and research lead into an acquaintance, confidante and friend. I initially learned of her challenges to carry a child to full term through proximity. As her teaching assistant I felt obliged to inform her that I had recently experienced an early miscarriage, and that it could possibly disrupt my work in her course. She was visibly pregnant at the time. Soon after, when I was participating in the resilience reading group, she miscarried as well. Reproductive Resilience A year or more passed before we spoke to each other about our losses, but when we did, we realised that we had both been influenced by dominant discourses around reproduction. Identifying the source of these pressures was an important topic of reflection for us. We found that dominant conceptions of reproductive resilience are overshadowed by a biological imperative to reproduce. When a woman is unable to conceive, or experiences a reproductive loss, she is told to ‘try again.’ There can be solace in trying, and in the ‘successful’ cases, a ‘happy resolution’ is achieved in subsequent pregnancies. But in other cases, the woman's body must produce several reproductive losses before medical professionals can understand the causes of her inability to reproduce (McMahon et al. 2007; Sexton, Byrd, and von Kluge 236). A series of increasingly invasive medical interventions can then be employed to increase the likelihood of reproduction. As a biological imperative, this type of reproductive resilience demands “progressive adaptation to a continually reinvented norm” (Walker and Cooper 156) of what it means to be fertile. But this is more than just a medical norm. Increasingly, reproduction also implies “adaptability to extremes of [ecological and economic] turbulence” (ibid.) that establish the conditions in which fertility is both experienced and understood, something that Katherine in particular had faced: Katherine: Why is it that we both ended up in this situation? Why is it that we are far from being alone in being 40 and childless? I am partly a product of the 1980s teen pregnancy hysteria in North America which made it an anathema for young women to ‘jeopardise’ their earning potential by having children. This makes me particularly bitter because I now understand that, at that moment in history, my society decided to prioritise my productive contributions to capital over socialised financing of the conditions that would allow me to produce a family. What I am suggesting is that the discourses which produce the preconceived notions that we attempt to ‘live up to’ are also discourses that we must, in many ways, ‘live with,’ because like it or not, they contributed to producing the situation which is now prompting us to write this paper! In this sense, reproductive resilience also becomes a measure of normalcy, where normalcy includes the adaptability of human bodies and biological process to the demands of a socio-economic system. Reproductive loss or infertility then becomes a source of personal weakness or abnormality that must be overcome, and a cause of personal degradation, which is often kept silent. In our experience, although individual responses differed greatly, either way the failure to reproduce demanded a response: Katherine: After my loss, I became determined to be pregnant again. For me IVF treatments were not so much about wanting to know with certainty my bodily ability to bring a child into the world. I was working under the perhaps rather desperate assumption that they would. I think of my IVF year more as desperation to achieve an end, a fear of failure, a crisis of sustainability, and a disbelief or disassociation from my own physical reality—the fact of my advancing age. The idea of ‘self-enclosed bodily anxiety’ captures this wonderfully for me. Ayumi: I did nothing, not a single consultation with a fertility expert, no visits to herbal medicine specialists, at most, a half-hearted internet search on adoption agencies. My path insisted upon embracing uncertainty over entrusting others with telling me the limits of my bodily integrity. When we began to share our stories with each other, we noticed that, despite having been surrounded by loving families and supportive colleagues at our times of crisis, both of us felt a tremendous sense of isolation as we tried to make sense of and respond to our losses. So a second area of reflection concerned the source of these emotions—both the sense of isolation, and the way in which it reinforced the normalisation of dominant discourses of reproductive resilience. We found that the reproductive industry’s medical interventions and specialised language community codify and reinforce measures of normalcy and sustain a coerced and often isolating process of adaptation to ever-more medicalised norms of fertility (Bonanno 753). This isolation is particularly apparent for women who choose to pursue fertility treatments. The language of medical intelligence is overwhelming and difficult to learn, creating a barrier between insiders and outsiders to fertility interventions (see for example: Kagan et al., S151). Fertility treatments are not only highly technical, but also a very introspective process, making it difficult for fertility partners, let alone friends and family, to fully comprehend what is going on, or to be involved. Meanwhile, support is difficult to find in a fertility clinic’s waiting room at 7am where groups of women silently await blood work to monitor hormone levels, avoiding eye contact by scanning their phones or reading a magazine. Many women turn instead to online forums, such as www.ivf.ca, where there is mutual comprehension wrapped in the security of anonymity. Rather than explain themselves each time they post to a forum, participants take up the language of reproductive medicine to detail their reproductive interventions in codified signature files (see Figure 1 below). Here, lengthy fertility campaigns become a merit badge of adaptability and perseverance. In their messages, participants share jingoistic mantras like ‘It only takes one!’, one harvested egg to have a child, as they cheer each other on in the search for a baby (Figure 2 below). These types of forums can empower insofar as they educate and encourage. However, they can also enclose and isolate as they cut patients off from family and friends, while creating external pressure to achieve a biological imperative suspended in changing parameters for what it means to be fertile. Figure 1: Example of a Signature File from an IVF Discussion Forum Figure 2: “It only takes one!” This kind of isolated adaptation to medicalised norms of fertility can come at a very high cost. For example, one friend was so traumatised by the multiple fertility interventions and failures it took for her to bear a child that she was ultimately unable to connect with the baby that she bore. The forward march of fertility treatments under the mounting pressure of advancing age required her to defer mourning for the multiple losses that she was experiencing: the loss of a child, the loss of normalcy, the loss of voice. She alone sustained the physical and psychological weight of reproductive resilience, and the pressures of achieving a ‘good outcome’ within the biological limits of her fertility window. When her daughter was born, she was engulfed by an avalanche of backlogged emotions—years of accumulated grief and stress. She was eventually diagnosed with post-traumatic stress disorder, and has struggled to develop a meaningful relationship with her child. But we also found that one need not pursue fertility treatments to experience the isolating and normalising effects of dominant conceptions of fertility. Some experienced infertility without feeling the need to consult medical professionals, or discover through initial consultations that a commercial and medicalised system was not the means through which they wanted to create a future for themselves. Others could find it difficult to contemplate the ‘reproduction’ of a ‘family’ when past experiences with family had been difficult. Yet, despite these decisions, changing norms of fertility continued to reinforce the biological imperative of reproduction in ways that become interwoven with tacitly heteronormative conceptualisations of the nature of family and community (Peters, Jackson, & Rudge 132-134). Katherine: Just the other day at the community garden, one of the gardeners, whom I had just met, wanted to know whether I had any children. When I said no, he bluntly asked me, ‘Why not?’ Just like that: ‘Why not?’ How can I even begin to answer this question? I’ve started to look people squarely in the eye and say, ‘I guess I must not be blessed.’ It’s not because I think I’m not blessed—my life is incredibly rewarding. It’s because it’s the best way I can think of to point out how inappropriate that line of questioning is. But I guess it’s also a defence… Ayumi: I do find that there is something deeply gendered and heterosexist about that line of questioning. As if there is some type of biological expectation for women to reproduce as a means to complete the family. And in absentia, in not raising the biological imperative with same-sex couples—in particular men, a whole host of assumptions are built into forming a good family. It’s like a double disrespect. In the first instance, the biological imperative falls on women, and in the second instance, the lack of expectation leaves many others out of the conversation. In total, we found that resilience always came with a modifier; otherwise we were left asking ‘resilience of what?’ ‘Resilience for what?’ Economic resilience, for example implied the adaptability of the capitalist system. Similarly, rather than expanding choices for and beyond women, the reproductive industry reinforced the normalcy of a gendered biological imperative that ultimately rested on the shoulders of an isolated individual. “The criteria of selection may well have shifted. Yet in the last instance, and for all its flexibility, the resilience perspective is no less rigorous in its selective function than Darwinian evolution” (Walker and Cooper 156). Dialogue Ayumi: To my surprise, she wanted to talk about it one day when we went for lunch, as though words would form the reality of her unexpected shift from pregnant to not-pregnant. The psychological experience of my own miscarriage had been devastating, so invisible, unannounced. Only those who needed to know were privy to the situation. Perhaps I quietly believed that if I spoke very little of it, it could almost have been mistaken for nothing other than conjecture or wishful thinking. Our conversation reproduced the reality of my failure to carry my child into childbirth. Her request for an empathetic listener would mean that a solitary introspection to resignify respect for my own body would give way to responding with due respect for her becoming no longer pregnant. Dialogue did more than just allow us to make sense of what we were experiencing. In conversation, reproductive resilience became something other than what we experienced in isolation. As experiences transformed into words, one perspective intermingled with and shaped the other, revealing imaginings that undid the closures and conclusions reached in our own minds, and offered an opportunity to reconsider the expectations of dominant narratives. Other possibilities surrounded, awaited contemplation, discursive engagement, solicitude in the shadows of experiences that coincided and diverged, resting assured that points of disagreement could be articulated as conjecture, wordless acknowledgement or future interactions. Our very different experiences and choices formed a context for conversation. We asked of one another: Why did this happen? How do you relate to your body? What do you feel is expected of you? What do you plan to do now? Upon dialogical reflection, it became clear that bodies, rather than being intentional enactments of adaptation, were more often than not products and reproductions of experiences and discourses: Ayumi: What kinds of biological, familial, technological, and economic imperatives are pressed upon our bodies? I wonder too about the ways in which consumerisation of reproduction plays upon our imagination of what it would be like to be a parent, creating a market and psychological demand for this life-changing acquisition of a human life. Perhaps these imperatives are operationalised as different mediations on the body, which is seen as a passive recipient of these directives. The externalisation and internalisation of our thoughts allowed us to see how our knowledge was suspended between our relationship with our body and the, often unexpressed, expectations of others which were based on their unexamined assumptions of what it meant to be a woman, a sexual being, a member of a family, a contributor to the community. Thinking about the body as something performed allowed us to use words to make real, reflect on, reproduce or recast our experiences: Katherine: I’m so independent, even in my relationship with my husband that I was a bit shocked at how my miscarriage rippled through my networks of friends, colleagues and family. People I hardly knew told me that they cried when they heard! I forget sometimes that my husband also suffered a huge loss, a blow to his identity and confidence, and a challenge to his sense of place. It is not just me who needs to engage with questions of resilience, but so does he, and we also need to do that together, and these processes will ripple through our networks of friends, family and co-workers in ways that affect the overall resiliency of a community of people. Ayumi: I talked to my partner about how deep down sometimes I feel that I've already done my work as a caregiver. I did a lot of volunteer and paid work with children when I was younger. I’ve taken care of so many children who ranged dramatically in age, mental and physical health and mobility, children who were dying and then died, and this took up so much of my teens, twenties and early thirties. I told him that while I've had that experience, he hasn't spent so much time with kids so that I wished for him to think about if this was something he wanted to explore (taking on a care giving / parental role), considering the options that are available to us through adoption or fostering. In dialogue, we figured out how to talk to one another, to locate a sense of fun within urgency, to reach toward mutual understanding, to test borders and to reshape them. Putting experiences and expectations into words allowed us to uncover expansive possibilities—options not considered, courses not taken. Ultimately, we began to think of reproductive resilience not as the means to achieve a biological imperative, but rather as a relational space of production. As we exchanged ideas, we came to question the assumption that reproductive resilience could be channeled through an individual body, and consequently we began to push back on definitions of fertility which served as measures of ‘fitness’ to a mythical adaptive whole. Through dialogue we resignified our individualised and isolated experiences with reproduction, turning what we experienced as vulnerability into a starting point for the reconceptualisation of resilience. This process—we call it ‘resiliency’ to distinguish it from adaptation—became an act of occupying our own reality in and through the relationships that surround us. Whereas resilience was about individual adaptations to shifting but still dominant norms of fertility, resiliency was about negotiating and constituting a fertile world through dialogues: Ayumi: I found our discussion of care a vitalising part of our conversations. Somehow, through forging different relations, the body propels resilience toward resisting external reinforcements to individualise reproduction and calls forth a collective response. Katherine: Today we discussed reproduction as a process of constructing a caring condition. Caring both in the sense of nurturing, but also in the sense of consideration. This was the most personally enriching part of our discussion – I felt empowered to make decisions about how I wanted to engage in caring and nurturing. This opened my mind to the possibility of adoption, but also to the fact that I express myself as a caring being in many other ways. Resiliency suggests actively engaging people and forces in ways that do not impose a certain order or state of affairs. But we struggled to think about how this new vision of reproductive resiliency would articulate with resistance. What does it mean to resist when biological failure renders acceptance of reproductive decline the only possible way forward? Though we can resist the conditions that created our current situations, we cannot resist our own pasts or our own biological reality. Should our inability to reproduce be seen as a victory in the fight against material myths of parental bliss? Or does our inability to reproduce make us the martyrs of the post-modern and neoliberal era? We want reproductive resiliency to offer a different experience of fertility. But we also want it to be a foundation to resist the normalisation of biological adaptation to the demands of a turbulent socio-economic system. We can do this by making a distinction between the biological act of reproduction (producing a baby), and the social reproducibility of care (nurturing, engaging, resisting, being, sharing, performing, etc.). Reproductive resiliency is concerned with nurturing the fertile enactments of human caring. It is on the basis of human caring that we can resist a system that creates the need for fertility adaptations, and it is also on this basis that we can open up room for thinking about reproductive resiliency in a respectful and socially engaged way. References Berkes, Fikret, Johan Colding and Carl Folke. “Introduction.” Navigating Social-Ecological Systems: Building Resilience for Complexity and Change. Ed. F. Berkes, J. Colding and C. Folke. Cambridge, U.K.: Cambridge University Press, 2002. Bonanno, George A. “Uses and Abuses of Resilience Construct: Loss, Trauma, and Health-Related Adversities. Social Science & Medicine 74.5 (2012): 753-756. Castleden, Matthew, Martin McGee, Virginia Murray & Giovanni Leonard. “Resilience Thinking in Health Protection. Journal of Public Health 33.3 (2011): 369-377. Cox, Pamela. “Marginalized Mothers, Reproductive Autonomy, and Repeat Losses to Care.” Journal of Law and Society 39.4 (2012): 541—561. Herrman, Helen, et al. “What Is Resilience?” Canadian J. of Psychiatry 56.5 (2011): 258-265. Hughes, Virginia. “The Roots of Resilience.” Nature 490 (2012): 165-167. Kagan, et al. “Improving Resilience among Infertile Women: A Pilot Study.” Fertility & Sterility 96.3 (2011): S151. McMahon, Catherine A., Frances L. Gibson, Jennifer L. Allen and Douglas Saunders. “Psychosocial Adjustment during Pregnancy for Older Couples Conceiving through Assisted Reproductive Technology.” Human Reproduction 22.4 (2007): 1168-1174. Peters, Kathleen, Debra Jackson, and Trudy Rudge. “Surviving the Adversity of Childlessness: Fostering Resilience in Couples.” Contemporary Nurse 40.1 (2011): 130-140. Sexton, Minden B., Michelle R. Byrd, and Silvia von Kluge. “Measuring Resilience in Women Experiencing Infertility Using the CD: RISC: Examining Infertility-Related Stress, General Stress, and Coping Styles.” Journal of Psychiatric Research 44.4 (2010): 236-241. Walker, Jeremy, and Melinda Cooper. “Genealogies of Resilience: From Systems Ecology to the Political Economy of Crisis Adaptation.” Security Dialogue 14.2 (2011): 143-160.

As a mode of open access public self-expression, blogs are one form of the unfolding massification of culture (Lovink). Though widely varied in content and style, they are characterised by a reverse chronological diary-like format, often produced by a single author, and often intimately expressive of that author’s thoughts and experiences. The purpose of this paper is to explore the use of blogs as a space for the detailed and on-going expression of the day to day experiences of sufferers of serious illness. We might traditionally consider the experience of illness as absolutely private, but illness, along with the process of recovery, retains a social and cultural aspect (Kleinman et al). A growing body of literature has recognised that the Internet has become a significant space for the recovery work that accompanies the diagnosis of serious illness (Orgad; Pitts; Hardey). Empowerment and agency are often emphasised in this literature, particularly in terms of the increased access to information and support groups, but also in the dynamic performances of self enabled by different forms of online communication and Web production. I am particularly interested in the ongoing shifts in the accessibility of “private” personal experience enabled by blog culture. Although there are thousands of others like them, three “illness blogs” have recently caught my attention for their candidness, completeness and complexity, expressing in vivid depth and detail individual lives transformed by serious illness. The late US journalist and television producer Leroy Sievers maintained a high profile blog, My Cancer, and weekly podcast on the National Public Radio website until his death from metastasised colon cancer in August 2008. Sievers used his public profile and the infrastructure of the NPR website to both detail his personal experience and bring together a community of people also affected by cancer or moved by his thoughts and experiences. The blogger Brainhell came to my attention through blogsphere comments and tributes when he died in February 2008. Spanning more than four years, Brainhell’s witty and charming blog attracted a significant audience and numerous comments, particularly toward the end of his life as the signs of his deteriorating motor system as a result of Amyotrophic Lateral Sclerosis (ALS, or “Lou Gherig’s disease”) riddled his intimate posts. Another blog of interest to me here, called Humanities Researcher, incorporates academic Stephanie Trigg’s period of illness and recovery from breast cancer within a pre-existing and ongoing blog about the intersection between professional and personal life. As I had crossed paths with Trigg while at Melbourne University, I was always interested in her blog. But her diagnosis with breast cancer and subsequent accounts of tests, the pain and debilitation of treatment and recovery within her blog also offer valuable insight into the role of online technologies in affecting experiences of illness and for the process of recovery.The subject matter of illness blogs revolves around significant personal transformations as a result of serious illness or trauma: transformations of everyday life, of body and emotional states, relationships, physical appearance, and the loss or recovery of physical ability. It is not my intention in this brief analysis to overgeneralise on the basis of some relatively limited observations. However, many blogs written in response to illness stand out for what they reveal about the shifting location or locatability of self, experience and the events of ongoing illness and thus how we can conceptualise the inherent “privacy” of illness as personal experience. Self-expression here is encompassing of the possibilities through which illness can be experienced – not as representation of that experience, a performance of a disembodied self (though these notions have their merits) – but an expressive element of the substance of the illness as it is experienced over time, as it affects the bodies, thoughts, events and relationships of individuals moving toward a state of full recovery or untimely death. Locating Oneself OnlineMany authors currently examining the role of online spaces in the lives of sufferers of serious illness see online communication as providing a means for configuring experience as a meaningful and coherent story, and thus conferring, or we could say recovering, a sense of agency amidst a tumultuous and ongoing battle with serious illness (Orgad, Pitts). In her study of breast cancer discussion forums, message boards and websites, Orgad (4) notes their role in regaining “the fundamentals disturbed by cancer” (see also Bury). Well before the emergence of online spaces, the act or writing has been seen as “a crucial affirmation of living, a statement against fearfulness, invisibility and silence” (Orgad, 67; Lorde, 61). For many decades scientists have asserted that “brief structured writing sessions can significantly improve mental and physical health for some groups of people” (Singer and Singer 485). The Internet has provided an infrastructure for bringing personal experiences of illness into the public realm, enabling a new level of visibility. Much of the work on illness and the Internet focuses on the liberatory and empowering act of story telling and “disembodied” self-expression. Discussion forums and cancer websites enable the formation of patient led “discourse communities” (Wuthnow). Online spaces such as discussion forums help their participants gain a foothold within a world they share with other sufferers, building communities of practice (Wegner) around specific forms of illness. In this way, these forms of self-expression and communication enable the sufferer of serious illness to counter the modes by which they are made “subjects”, in the Foucauldian sense, of medical discourse. All illness narratives are defined and constructed socially, and are infused with relations of power (Sontag; Foucault, Birth of the Clinic). Forms of online communication have shifted productive practice from professions to patients. Blogs, like discussion forums, websites, email lists etc., have come to play a central role in this contemporary shift. When Lovink (6) describes blogs as a “technology of the self” he points to their role in “self-fashioning”. Blogs written about and in the context of personal illness are a perfect example of this inclination to speak the truth of oneself in the confessional mode of modern culture borne of the church, science and talkshow television. For Foucault (Technologies of the Self, 17), technologies of the self: Permit individuals to effect by their own means or with the help of others a certain number of operations on their own bodies and souls, thoughts, conduct and way of being, so as to transform themselves in order to attain a state of happiness, purity, wisdom, perfection, immortality. Likewise, as a central concept for understanding Internet identity, the notion of performance (eg, Turkle) highlights the creativity with which illness bloggers may present their role as cancer patient in online spaces, perhaps as an act of resistance to “subjectifying” medical discourses and practices. Many bloggers wrest semiotic power through regular discussion of the language of pathology and medical knowledge, treatment processes and drugs. In the early stages of her treatment, Trigg plays with the new vocabulary, searching for etiologies and making her own semantic connections: I’ve learnt two new words. “Spiculated” describes the characteristic shape of a carcinoma on an ultrasound or x-ray. …The other word is at the other end of the spectrum of linguistic beauty: “lumpectomy”. It took me quite a while to realise that this was not really any different from partial mastectomy; or local excision. It’s an example of the powerful semantic connotations of words to realise that these phrases name the same processes: a long cut, and then the extraction of the diseased tissue (Humanities Researcher, 14 Oct. 2006).Partly due to the rarity of his illness, Brainhell goes through weeks of waiting for a diagnosis, and posts prolifically in an attempt to test out self-diagnoses. Amidst many serious and humorous posts analysing test results and discussing possible diagnoses Brainhell reflects on his targeted use of the blog: I am a word person. I think in sentences. I often take complex technical problems at work and describe them to myself in words. A story helps me understand things better. This blog has become a tool for me to organize my own thoughts about the Mystery Condition. (Brainhell, 6 Jan. 2004)The emancipatory potential of blog writing, however, can be easily overstated. While it is valuable to note and celebrate the performative potential of online production, and its “transformative” role as a technology of the self, it is easy to fall back on an unproblematic distinction between the actual and the virtual, the experience of illness, and its representation in online spaces. Textual expression should always refer us to the extra-textual practices that encompass it without imposing an artificial hierarchy of online and offline, actual experience and representation. As with other forms of online communication and production, the blog culture that has emerged around forms of serious illness plays a significant role in transforming our concepts of the relationship between online and offline spaces. In his My Cancer blog, Sievers often refers to “Cancer World”. He notes, for example, the many “passing friends” he makes in Cancer World through the medical staff and other regular patients at the radiation clinic, and refers to the equipment that sustains his life as the accoutrements of this world. His blog posts revolved around an articulation of the intricacies of this “world” that is in some ways a means of making sense of that world, but is also expressive of it. Sievers tries to explain the notion of Cancer World as a transformation of status between insider & outsider: “once we cross over into Cancer World, we become strangers in a strange land. What to expect, what to hope for, what to fear – none of those are clear right now” (My Cancer, 30 June 2008). Part of his struggle with the illness is also with the expression of himself as encompassed by this new “world” of the effects and activities of cancer. In a similar way, in her Humanities Researcher blog Trigg describes in beautiful detail the processes, routines and relationships formed during radiation treatment. I see these accounts of the textures of cancer spaces as lying at the point of juncture between expression and experience, not as a disembodied, emancipatory realm free from the fetters of illness and the everyday “real” self, but always encompassed by, and encompassing them, and in this way shifting what might be understood to remain “private” in personal experience and self-expression. Blogs as Public Diary Axel Bruns (171), following Matthew Rothenberg, characterises blogs as an accessible technological extension of the personal home page, gaining popularity in the late 1990s because they provided more easy to use templates and web publishing tools than earlier webpage applications. Personalised self expression is a defining element. However, the temporal quality of the reverse chronological, timestamped entry is equally significant for Bruns (171). Taking a broader focus to Bruns, who is most interested in the potential democratisation of media in news related blogs, Lovink sees the experimentation with a “public diary” format as fundamental, signalling their “productive contradiction between public and private” (Lovink 6). A diary may be written for posterity but it is primarily a secretive mode of communication. While blogs may mirror the temporal form of a diary, their intimate focus on self-expression of experience, thoughts and feelings, they do so in a very different communicative context.Despite research suggesting that a majority of bloggers report that they post primarily “for themselves” (Lenhart and Fox) – meaning that they do not deliberately seek a broad audience or readership – the step of making experiences and thoughts so widely accessible cannot be overlooked in any account of blogging. The question of audience or readership, for example, concerns Trigg in her Humanities Researcher blog: The immediacy of a blog distinguishes it from a journal or diary. I wrote for myself, of course, but also for a readership I could measure and chart and hear from, sometimes within minutes of posting. Mostly I don’t know who my readers are, but the kindness and friendship that come to me through the blog gave me courage to write about the intimacies of my treatment; and to chart the emotional upheaval it produced. (Trigg)In their ability to produce a comprehensive expression of the events, experiences, thoughts and feelings of an individual, blogs differ to other forms of online communication such as discussion forums or email lists. Illness blogs are perhaps an extreme example, an open mode of self-expression often arising abruptly in reaction to a life transforming diagnosis and tracking the process of recovery or deterioration, usually ending with remission or death. Brainhell’s blog begins with MRI results, and a series of posts about medical examination and self-examination regarding his mystery condition: So the MRI shows there is something on my brain that is not supposed to be there. The doctor thinks it is not a tumor. That would be good news. …As long as you are alive and have someone to complain to, you ain’t bad off. I am alive and I am complaining about a mystery spot on my brain, and lazy limbs. (Brainhell, 24 Dec. 2003)Brainhell spent many weeks documenting his search for a diagnosis, and continued writing up to his final deterioration and death in 2008. His final posts convey his physical deterioration in truncated sentences, spelling errors and mangled words. In one post he expresses his inability to wake his caregiver and to communicate his distress and physical discomfort at having to pee: when he snorted on waking, i shrieked and he got me up. splayed uncomfortably in the wc as he put dry clothes on me, i was gifted with his words: “you choose this, not me. you want to make it hard, what can i do?” (Brainhell, 13 Jan. 2008). The temporal and continuous format of the blog traverses the visceral, corporeal transformations of body and thought over time. The diary format goes beyond a straightforward narrative form in being far more experiential and even experimental in its self-reflective expression of the events of daily life, thoughts, feelings and states of being. Its public format bears directly on its role in shaping the communicative context in which that expression takes place, and thus to an extent shapes the experience of the illness itself. Nowhere does the expressive substance of the blog so fully encompass the possibilities through which the illness could be experienced than in the author’s death. At this point the blog feels like it is more than a catalogue, dialogue or self-presentation of a struggle with illness. It may take on the form of a memorial (see for example Tom’s Road to Recovery) – a recovery of the self expressed in the daily physical demise, through data maintained in the memory of servers. Ultimately the blog stands as a complex trace of the life lived within its posts. Brainhell’s lengthy blog exemplifies this quite hauntingly. Revealing the Private in Public Blogs exemplify a further step in the transformation of notions of public and private brought about by information and screen technologies. McQuire (103) refers to contemporary screen and Internet culture as “a social setting in which personal identity is subject to new exigencies”. Reality television, such as Big Brother, has promoted “a new mode for the public viewing of private life” (McQuire 114) contributing to the normalisation of open access to personal, intimate revelations, actions and experiences. However, privacy is “an elusive concept” that relates as much to information and property as to self-expression and personal experience (McCullagh). That is, what we consider private to an individual is itself constituted by our variable categories of personal information, material or immaterial possessions, or what counts as an expression of personal experience. Some analysts of online storytelling in the context of illness recognise the unsustainability of the distinction between public and private, but nonetheless rely on the notion of a continuum upon which activities or events could be considered as experienced in a public or private space (Orgad, 129-133). One of the characteristics of a blog, unlike other forms of online communication such as chat, discussion forums and email, is its predominantly public and openly accessible form. Though many illness bloggers do not seem to seek anonymity or hold back in allowing massive access to their self-expression and personal experience, a tension always seems to be there in the background. Identification through the proper name simply implies potential broader effects of blog writing, a pairing of the personal expressions with the person who expresses them in broader daily interactions and relationships. As already “public” figures, Stephanie Trigg and Leroy Sievers choose to forego anonymity, while Brainhell adopted his alias from the beginning and guarded his anonymity carefully. Each of these bloggers, however, shows signs of grappling with the public character of their site, and the interaction between the blog and their everyday life and relationships. In his etiquette page, Brainhell seems unclear about his readership, noting that his blog is for “friends and soul-mates, and complete strangers too”, but that he has not shared it with his family or all of his friends. He goes on to say: You may not have been invited but you are still welcome here. I made it public so that anyone could read it. Total strangers are welcome. Invited friends are welcome. But of those invited friends, I ask you to ask me before you out me as the blog author, or share the blog with other people who already know me. (Brainhell, 18 Feb. 2004) After his death Ratty took steps to continue to maintain his anonymity, vetting many comments and deleting others to “honor BH’s wishes as he outline in ‘Ettiquett for This Blog”’ (Brainhell, 2 Feb. 2008). In Leroy Sievers’ blog, one post exploring the conflict raised by publicly “sharing” his experiences provoked an interesting discussion. He relays a comment sent to him by a woman named Cherie: I have stage four colorectal cancer with liver mets. This is a strange journey, one I am not entirely sure I can share with my loved ones. I am scared it might rob them of the hope I see in their eyes. The hope which I sometimes don’t believe in. (My Cancer, 26 July 2006) Sievers struggles with this question: “How do you balance the need to talk about what is happening to you with the tears of a close friend when you tell him or her the truth? There’s no simple answer.” The blog, in this sense, seems to offer a more legitimate space for the ongoing, detailed expression of these difficult and affective, and traditionally private experiences. In some posts the privacy of the body and bodily experiences is directly challenged or re-negotiated. Stephanie Trigg was concerned with the effect of the blog on her interactions with colleagues. But another interesting dilemma presents itself to her when she is describing the physical effects of cancer, surgery and radiation treatment on her breast, and forces herself to hold back from comparing with the healthy breast: “it's not a medical breast, so I can't write about it here” (Humanities Researcher, 10 Jan. 2007). One prostate cancer blogger, identified as rdavisjr, seems to have no difficulties expressing the details of a physical intrusion on his “privacy” in the far more open forum of his blog: The pull-around ceiling mounted screen was missing (laundry?), so Kelly was called into the room and told to make a screen with a bed sheet. So here I am with one woman sticking her finger up my ass, while another woman is standing in front of the door holding an outstretched bed sheet under her chin (guess she wanted a view!)The screen was necessary to ensure my privacy in the event someone accidentally came into the room, something they said was a common thing. Well, Kelly peering over that sheet was hardly one of my more private moments in life! (Prostate Cancer Journal, 23 Feb. 2001). ConclusionWhatever emancipatory benefits may be found in expressing the most intimate of experiences and events of a serious illness online, it is the creative act of the blog as self-expression here, in its visceral, comprehensive, continuous timestamped format that dismantles the sense of privacy in the name of recovery. The blog is not the public face of private personal experience, but expressive of the life encompassed by that illness, and encompassing its author’s ongoing personal transformation. The blogs discussed here are not alone in demonstrating these practices. The blog format itself may soon evolve or disappear. Nonetheless, the massification enabled by Internet technologies and applications will continue to transform the ways in which personal experience may be considered private. ReferencesBruns, Axel. Gatewatching: Collaborative Online News Production. New York: Peter Lang, 2005.Bury, Michael. “Chronic Illness as Biographical Disruption.” Sociology of Health and Illness, 4.2 (1982): 167-182.Foucault, Michel. Birth of the Clinic: An Archaeology of Medical Perception. Trans. A.M. Sheridan. London: Tavistock, 1973.———. “Technologies of the Self” Technologies of the Self: A Seminar with Michel Foucault. Ed. Luther H. Martin, Huck Gutman, Patrick M. Hutton, 1988: 16-49. Hardey, Michael. “‘The Story of My Illness’: Personal Accounts of Illness on the Internet.” Health 6.1 (2002): 31-46Kleinman, Arthur, Veena Das, and Margaret Lock, eds. Social Suffering. Berkeley: University of California Press, 1997. Lenhart, Amanda, and Susannah Fox. Bloggers: A Portrait of the Internet’s New Storytellers. Washington: PEW Internet and American Life Project, 2006. Lorde, Audre. The Cancer Journals. San Francisco: Spinsters Ink, 1980.Lovink, Geert. Zero Comments: Blogging and Critical Internet Culture. London: Routledge, 2008. McCullagh, Karen. “Blogging: Self Presentation and Privacy.” Information and Communications Technology Law 17.1 (2008): 3-23. McQuire, Scott. “From Glass Architecture to Big Brother: Scenes from a Cultural History of Transparency.” Cultural Studies Review 9.1 (2003): 103-123.Orgad, Shani. Storytelling Online: Talking Breast Cancer on the Internet. New York: Peter Lang, 2005. Pitts, Victoria. “Illness and Internet Empowerment: Writing and Reading Breast Cancer in Cyberspace.” Health 8.1 (2004): 33-59.Rothenberg, Matthew. “Weblogs, Metadata, and the Semantic Web”, paper presented at the Association of Internet Researchers conference, Toronto, 16 Oct. 2003. ‹http://aoir.org/members/papers42/rothenberg_aoir.pdf›.Singer, Jessica, and George H.S. Singer. “Writing as Physical and Emotional Healing: Findings from Clinical Research.” Handbook of Research on Writing: History, Society, School, Individual, Text. Ed. Charles Bazerman. New York: Lawrence Erlbaum Associates, 2008: 485-498. Sontag, Susan. Illness as Metaphor; And, AIDS and Its Metaphors. London: Penguin, 1991. Trigg, Stephanie. “Life Lessons.” Sunday Age, 10 June 2007. Turkle, Sherry. Life on the Screen: Identity in the Age of the Internet. New York: Simon and Schuster, 1995. Wenger, Etienne. Communities of Practice: Learning, Meaning and Identity. Cambridge: Cambridge University Press, 1998. Wuthnow, Robert. Communities of Discourse: Ideology and Social Structure in the Reformation, the Enlightenment, and European Socialism. Cambridge, MA: Harvard University Press, 1989.BlogsBrainhell. ‹http://brainhell.blogspot.com/›. rdavisjr. Prostate Cancer Journal. ‹http://pcjournal-rrd.blogspot.com/›. Sievers, Leroy. My Cancer. ‹http://www.npr.org/blogs/mycancer/›. Tom’s Road to Recovery. ‹http://tomsrecovery.blog.com/›. Trigg, Stephanie. Humanities Researcher. ‹http://stephanietrigg.blogspot.com/›.

'He did what the cipher could not, he rescued himself.' -- Alfred Bester, The Stars My Destination (23) On many levels, the new Nine Inch Nails album The Fragile is a gritty meditation about different types of End: the eternal relationship cycle of 'fragility, tension, ordeal, fragmentation' (adapted, with apologies to Wilhelm Reich); fin-de-siècle anxiety; post-millennium foreboding; a spectre of the alien discontinuity that heralds an on-rushing future vastly different from the one envisaged by Enlightenment Project architects. In retrospect, it's easy for this perspective to be dismissed as jargon-filled cyber-crit hyperbole. Cyber-crit has always been at its best too when it invents pre-histories and finds hidden connections between different phenomena (like the work of Greil Marcus and early Mark Dery), and not when it is closer to Chinese Water Torture, name-checking the canon's icons (the 'Deleuze/Guattari' tag-team), texts and key terms. "The organization of sound is interpreted historically, politically, socially ... . It subdues music's ambition, reins it in, restores it to its proper place, reconciles it to its naturally belated fate", comments imagineer Kodwo Eshun (4) on how cyber-crit destroys albums and the innocence of the listening experience. This is how official histories are constructed a priori and freeze-dried according to personal tastes and prior memes: sometimes the most interesting experiments are Darwinian dead-ends that fail to make the canon, or don't register on the radar. Anyone approaching The Fragile must also contend with the music industry's harsh realities. For every 10 000 Goth fans who moshed to the primal 'kill-fuck-dance' rhythms of the hit single "Closer" (heeding its siren-call to fulfil basic physiological needs and build niche-space), maybe 20 noted that the same riff returned with a darker edge in the title track to The Downward Spiral, undermining the glorification of Indulgent hedonism. "The problem with such alternative audiences," notes Disinformation Creative Director Richard Metzger, "is that they are trying to be different -- just like everyone else." According to author Don Webb, "some mature Chaos and Black Magicians reject their earlier Nine Inch Nails-inspired Goth beginnings and are extremely critical towards new adopters because they are uncomfortable with the subculture's growing popularity, which threatens to taint their meticulously constructed 'mysterious' worlds. But by doing so, they are also rejecting their symbolic imprinting and some powerful Keys to unlocking their personal history." It is also difficult to separate Nine Inch Nails from the commercialisation and colossal money-making machine that inevitably ensued on the MTV tour circuit: do we blame Michael Trent Reznor because most of his audience are unlikely to be familiar with 'first-wave' industrial bands including Cabaret Voltaire and the experiments of Genesis P. Orridge in Throbbing Gristle? Do we accuse Reznor of being a plagiarist just because he wears some of his influences -- Dr. Dre, Daft Punk, Atari Teenage Riot, Pink Floyd's The Wall (1979), Tom Waits's Bone Machine (1992), David Bowie's Low (1977) -- on his sleeve? And do we accept no-brain rock critic album reviews who quote lines like 'All the pieces didn't fit/Though I really didn't give a shit' ("Where Is Everybody?") or 'And when I suck you off/Not a drop will go to waste' ("Starfuckers Inc") as representative of his true personality? Reznor evidently has his own thoughts on this subject, but we should let the music speak for itself. The album's epic production and technical complexity turned into a post-modern studio Vision Quest, assisted by producer Alan Moulder, eleventh-hour saviour Bob Ezrin (brought in by Reznor to 'block-out' conceptual and sonic continuity), and a group of assault-technicians. The fruit of these collaborations is an album where Reznor is playing with our organism's time-binding sense, modulating strange emotions through deeply embedded tonal angularities. During his five-year absence, Trent Reznor fought diverse forms of repetitious trauma, from endogenous depression caused by endless touring to the death of his beloved grandmother (who raised him throughout childhood). An end signals a new beginning, a spiral is an open-ended and ever-shifting structure, and so Reznor sought to re-discover the Elder Gods within, a shamanic approach to renewal and secular salvation utilised most effectively by music PR luminary and scientist Howard Bloom. Concerned with healing the human animal through Ordeals that hard-wire the physiological baselines of Love, Hate and Fear, Reznor also focusses on what happens when 'meaning-making' collapses and hope for the future cannot easily be found. He accurately captures the confusion that such dissolution of meaning and decline of social institutions brings to the world -- Francis Fukuyama calls this bifurcation 'The Great Disruption'. For a generation who experienced their late childhood and early adolescence in Reagan's America, Reznor and his influences (Marilyn Manson and Filter) capture the Dark Side of recent history, unleashed at Altamont and mutating into the Apocalyptic style of American politics (evident in the 'Star Wars'/SDI fascination). The personal 'psychotic core' that was crystallised by the collapse of the nuclear family unit and supportive social institutions has returned to haunt us with dystopian fantasies that are played out across Internet streaming media and visceral MTV film-clips. That such cathartic releases are useful -- and even necessary (to those whose lives have been formed by socio-economic 'life conditions') is a point that escapes critics like Roger Scruton, some Christian Evangelists and the New Right. The 'escapist' quality of early 1980s 'Rapture' and 'Cosmocide' (Hal Lindsey) prophecies has yielded strange fruit for the Children of Ezekiel, whom Reznor and Marilyn Manson are unofficial spokes-persons for. From a macro perspective, Reznor's post-human evolutionary nexus lies, like J.G. Ballard's tales, in a mythical near-future built upon past memory-shards. It is the kind of worldview that fuses organic and morphogenetic structures with industrial machines run amok, thus The Fragile is an artefact that captures the subjective contents of the different mind produced by different times. Sonic events are in-synch but out of phase. Samples subtly trigger and then scramble kinaesthetic-visceral and kinaesthetic-tactile memories, suggestive of dissociated affective states or body memories that are incapable of being retrieved (van der Kolk 294). Perhaps this is why after a Century of Identity Confusion some fans find it impossible to listen to a 102-minute album in one sitting. No wonder then that the double album is divided into 'left' and 'right' discs (a reference to split-brain research?). The real-time track-by-track interpretation below is necessarily subjective, and is intended to serve as a provisional listener's guide to the aural ur-text of 1999. The Fragile is full of encrypted tones and garbled frequencies that capture a world where the future is always bleeding into a non-recoverable past. Turbulent wave-forms fight for the listener's attention with prolonged static lulls. This does not make for comfortable or even 'nice' listening. The music's mind is a snapshot, a critical indicator, of the deep structures brewing within the Weltanschauung that could erupt at any moment. "Somewhat Damaged" opens the album's 'Left' disc with an oscillating acoustic strum that anchor's the listener's attention. Offset by pulsing beats and mallet percussion, Reznor builds up sound layers that contrast with lyrical epitaphs like 'Everything that swore it wouldn't change is different now'. Icarus iconography is invoked, but perhaps a more fitting mythopoeic symbol of the journey that lies ahead would be Nietzsche's pursuit of his Ariadne through the labyrinth of life, during which the hero is steadily consumed by his numbing psychosis. Reznor fittingly comments: 'Didn't quite/Fell Apart/Where were you?' If we consider that Reznor has been repeating the same cycle with different variations throughout all of his music to date, retro-fitting each new album into a seamless tapestry, then this track signals that he has begun to finally climb out of self-imposed exile in the Underworld. "The Day the World Went Away" has a tremendously eerie opening, with plucked mandolin effects entering at 0:40. The main slashing guitar riff was interpreted by some critics as Reznor's attempt to parody himself. For some reason, the eerie backdrop and fragmented acoustic guitar strums recalls to my mind civil defence nuclear war films. Reznor, like William S. Burroughs, has some powerful obsessions. The track builds up in intensity, with a 'Chorus of the Damned' singing 'na na nah' over apocalyptic end-times imagery. At 4:22 the track ends with an echo that loops and repeats. "The Frail" signals a shift to mournful introspectiveness with piano: a soundtrack to faded 8 mm films and dying memories. The piano builds up slowly with background echo, holds and segues into ... "The Wretched", beginning with a savage downbeat that recalls earlier material from Pretty Hate Machine. 'The Far Aways/Forget It' intones Reznor -- it's becoming clear that despite some claims to the contrary, there is redemption in this album, but it is one borne out of a relentless move forward, a strive-drive. 'You're finally free/You could be' suggest Reznor studied Existentialism during his psychotherapy visits. This song contains perhaps the ultimate post-relationship line: 'It didn't turn out the way you wanted it to, did it?' It's over, just not the way you wanted; you can always leave the partner you're with, but the ones you have already left will always stain your memories. The lines 'Back at the beginning/Sinking/Spinning' recall the claustrophobic trapped world and 'eternal Now' dislocation of Post-Traumatic Stress Disorder victims. At 3:44 a plucked cello riff, filtered, segues into a sludge buzz-saw guitar solo. At 5:18 the cello riff loops and repeats. "We're in This Together Now" uses static as percussion, highlighting the influence of electricity flows instead of traditional rock instrument configurations. At 0:34 vocals enter, at 1:15 Reznor wails 'I'm impossible', showing he is the heir to Roger Waters's self-reflective rock-star angst. 'Until the very end of me, until the very end of you' reverts the traditional marriage vow, whilst 'You're the Queen and I'm the King' quotes David Bowie's "Heroes". Unlike earlier tracks like "Reptile", this track is far more positive about relationships, which have previously resembled toxic-dyads. Reznor signals a delta surge (breaking through barriers at any cost), despite a time-line morphing between present-past-future. At 5:30 synths and piano signal a shift, at 5:49 the outgoing piano riff begins. The film-clip is filled with redemptive water imagery. The soundtrack gradually gets more murky and at 7:05 a subterranean note signals closure. "The Fragile" is even more hopeful and life-affirming (some may even interpret it as devotional), but this love -- representative of the End-Times, alludes to the 'Glamour of Evil' (Nico) in the line 'Fragile/She doesn't see her beauty'. The fusion of synths and atonal guitars beginning at 2:13 summons forth film-clip imagery -- mazes, pageants, bald eagles, found sounds, cloaked figures, ruined statues, enveloping darkness. "Just like You Imagined" opens with Soundscapes worthy of Robert Fripp, doubled by piano and guitar at 0:39. Drums and muffled voices enter at 0:54 -- are we seeing a pattern to Reznor's writing here? Sonic debris guitar enters at 1:08, bringing forth intensities from white noise. This track is full of subtle joys like the 1:23-1:36 solo by David Bowie pianist Mike Garson and guitarist Adrian Belew's outgoing guitar solo at 2:43, shifting back to the underlying soundscapes at 3:07. The sounds are always on the dissipative edge of chaos. "Just like You Imagined" opens with Soundscapes worthy of Robert Fripp, doubled by piano and guitar at 0:39. Drums and muffled voices enter at 0:54 -- are we seeing a pattern to Reznor's writing here? Sonic debris guitar enters at 1:08, bringing forth intensities from white noise. This track is full of subtle joys like the 1:23-1:36 solo by David Bowie pianist Mike Garson and guitarist Adrian Belew's outgoing guitar solo at 2:43, shifting back to the underlying soundscapes at 3:07. The sounds are always on the dissipative edge of chaos. "Pilgrimage" utilises a persistent ostinato and beat, with a driving guitar overlay at 0:18. This is perhaps the most familiar track, using Reznor motifs like the doubling of the riff with acoustic guitars between 1:12-1:20, march cries, and pitch-shift effects on a 3:18 drumbeat/cymbal. Or at least I could claim it was familiar, if it were not that legendary hip-hop producer and 'edge-of-panic' tactilist Dr. Dre helped assemble the final track mix. "No, You Don't" has been interpreted as an attack on Marilyn Manson and Hole's Courntey Love, particularly the 0:47 line 'Got to keep it all on the outside/Because everything is dead on the inside' and the 2:33 final verse 'Just so you know, I did not believe you could sink so low'. The song's structure is familiar: a basic beat at 0:16, guitars building from 0:31 to sneering vocals, a 2:03 counter-riff that merges at 2:19 with vocals and ascending to the final verse and 3:26 final distortion... "La Mer" is the first major surprise, a beautiful and sweeping fusion of piano, keyboard and cello, reminiscent of Symbolist composer Debussy. At 1:07 Denise Milfort whispers, setting the stage for sometime Ministry drummer Bill Reiflin's jazz drumming at 1:22, and a funky 1:32 guitar/bass line. The pulsing synth guitar at 2:04 serves as anchoring percussion for a cinematic electronica mindscape, filtered through new layers of sonic chiaroscuro at 2:51. 3:06 phase shifting, 3:22 layer doubling, 3:37 outgoing solo, 3:50-3:54 more swirling vocal fragments, seguing into a fading cello quartet as shadows creep. David Carson's moody film-clip captures the end more ominously, depicting the beauty of drowning. This track contains the line 'Nothing can stop me now', which appears to be Reznor's personal mantra. This track rivals 'Hurt' and 'A Warm Place' from The Downward Spiral and 'Something I Can Never Have' from Pretty Hate Machine as perhaps the most emotionally revealing and delicate material that Reznor has written. "The Great Below" ends the first disc with more multi-layered textures fusing nostalgia and reverie: a twelve-second cello riff is counter-pointed by a plucked overlay, which builds to a 0:43 washed pulse effect, transformed by six second pulses between 1:04-1:19 and a further effects layer at 1:24. E-bow effects underscore lyrics like 'Currents have their say' (2:33) and 'Washes me away' (2:44), which a 3:33 sitar riff answers. These complexities are further transmuted by seemingly random events -- a 4:06 doubling of the sitar riff which 'glitches' and a 4:32 backbeat echo that drifts for four bars. While Reznor's lyrics suggest that he is unable to control subjective time-states (like The Joker in the Batman: Dark Knight series of Kali-yuga comic-books), the track constructions show that the Key to his hold over the listener is very carefully constructed songs whose spaces resemble Pythagorean mathematical formulas. Misdirecting the audience is the secret of many magicians. "The Way Out Is Through" opens the 'Right' disc with an industrial riff that builds at 0:19 to click-track and rhythm, the equivalent of a weaving spiral. Whispering 'All I've undergone/I will keep on' at 1:24, Reznor is backed at 1:38 by synths and drums coalescing into guitars, which take shape at 1:46 and turn into a torrential electrical current. The models are clearly natural morphogenetic structures. The track twists through inner storms and torments from 2:42 to 2:48, mirrored by vocal shards at 2:59 and soundscapes at 3:45, before piano fades in and out at 4:12. The title references peri-natal theories of development (particularly those of Stanislav Grof), which is the source of much of the album's imagery. "Into the Void" is not the Black Sabbath song of the same name, but a catchy track that uses the same unfolding formula (opening static, cello at 0:18, guitars at 0:31, drums and backbeat at 1:02, trademark industrial vocals and synth at 1:02, verse at 1:23), and would not appear out of place in a Survival Research Laboratories exhibition. At 3:42 Reznor plays with the edge of synth soundscapes, merging vocals at 4:02 and ending the track nicely at 4:44 alone. "Where Is Everybody?" emulates earlier structures, but relies from 2:01 on whirring effects and organic rhythms, including a flurry of eight beat pulses between 2:40-2:46 and a 3:33 spiralling guitar solo. The 4:26 guitar solo is pure Adrian Belew, and is suddenly ended by spluttering static and white noise at 5:13. "The Mark Has Been Made" signals another downshift into introspectiveness with 0:32 ghostly synth shimmers, echoed by cello at 1:04 which is the doubled at 1:55 by guitar. At 2:08 industrial riffs suddenly build up, weaving between 3:28 distorted guitars and the return of the repressed original layer at 4:16. The surprise is a mystery 32 second soundscape at the end with Reznor crooning 'I'm getting closer, all the time' like a zombie devil Elvis. "Please" highlights spacious noise at 0:48, and signals a central album motif at 1:04 with the line 'Time starts slowing down/Sink until I drown'. The psychic mood of the album shifts with the discovery of Imagination as a liberating force against oppression. The synth sound again is remarkably organic for an industrial album. "Starfuckers Inc" is the now infamous sneering attack on rock-stardom, perhaps at Marilyn Manson (at 3:08 Reznor quotes Carly Simon's 'You're So Vain'). Jungle beats and pulsing synths open the track, which features the sound-sculpting talent of Pop Will Eat Itself member Clint Mansell. Beginning at 0:26, Reznor's vocals appear to have been sampled, looped and cut up (apologies to Brion Gysin and William S. Burroughs). The lines 'I have arrived and this time you should believe the hype/I listened to everyone now I know everyone was right' is a very savage and funny exposure of Manson's constant references to Friedrich Nietzsche's Herd-mentality: the Herd needs a bogey-man to whip it into submission, and Manson comes dangerous close to fulfilling this potential, thus becoming trapped by a 'Stacked Deck' paradox. The 4:08 lyric line 'Now I belong I'm one of the Chosen Ones/Now I belong I'm one of the Beautiful Ones' highlights the problem of being Elect and becoming intertwined with institutionalised group-think. The album version ditches the closing sample of Gene Simmons screaming "Thankyou and goodnight!" to an enraptured audience on the single from KISS Alive (1975), which was appropriately over-the-top (the alternate quiet version is worth hearing also). "The danger Marilyn Manson faces", notes Don Webb (current High Priest of the Temple of Set), "is that he may end up in twenty years time on the 'Tonight Show' safely singing our favourite songs like a Goth Frank Sinatra, and will have gradually lost his antinomian power. It's much harder to maintain the enigmatic aura of an Evil villain than it is to play the clown with society". Reznor's superior musicianship and sense of irony should keep him from falling into the same trap. "Complication" juggernauts in at 0:57 with screaming vocals and a barrage of white noise at 1:56. It's clear by now that Reznor has read his psychological operations (PSYOP) manuals pertaining to blasting the hell out of his audiences' psyche by any means necessary. Computer blip noise and black light flotation tank memories. Dislocating pauses and time-bends. The aural equivalent of Klein bottles. "Complication" juggernauts in at 0:57 with screaming vocals and a barrage of white noise at 1:56. It's clear by now that Reznor has read his psychological operations (PSYOP) manuals pertaining to blasting the hell out of his audiences' psyche by any means necessary. Computer blip noise and black light flotation tank memories. Dislocating pauses and time-bends. The aural equivalent of Klein bottles. "The Big Come Down" begins with a four-second synth/static intro that is smashed apart by a hard beat at 0:05 and kaleidoscope guitars at 0:16. Critics refer to the song's lyrics in an attempt to project a narcissistic Reznor personality, but don't comment on stylistic tweaks like the AM radio influenced backing vocals at 1:02 and 1:19, or the use of guitars as a percussion layer at 1:51. A further intriguing element is the return of the fly samples at 2:38, an effect heard on previous releases and a possible post-human sub-text. The alien mythos will eventually reign over the banal and empty human. At 3:07 the synths return with static, a further overlay adds more synths at 3:45 as the track spirals to its peak, before dissipating at 3:1 in a mesh of percussion and guitars. "Underneath It All" opens with a riff that signals we have reached the album's climatic turning point, with the recurring theme of fragmenting body-memories returning at 0:23 with the line 'All I can do/I can still feel you', and being echoed by pulsing static at 0:42 as electric percussion. A 'Messiah Complex' appears at 1:34 with the line 'Crucify/After all I've died/After all I've tried/You are still inside', or at least it appears to be that on the surface. This is the kind of line that typical rock critics will quote, but a careful re-reading suggests that Reznor is pointing to the painful nature of remanifesting. Our past shapes us more than we would like to admit particularly our first relationships. "Ripe (With Decay)" is the album's final statement, a complex weaving of passages over a repetitive mesh of guitars, pulsing echoes, back-beats, soundscapes, and a powerful Mike Garson piano solo (2:26). Earlier motifs including fly samples (3:00), mournful funeral violas (3:36) and slowing time effects (4:28) recur throughout the track. Having finally reached the psychotic core, Reznor is not content to let us rest, mixing funk bass riffs (4:46), vocal snatches (5:23) and oscillating guitars (5:39) that drag the listener forever onwards towards the edge of the abyss (5:58). The final sequence begins at 6:22, loses fidelity at 6:28, and ends abruptly at 6:35. At millennium's end there is a common-held perception that the world is in an irreversible state of decay, and that Culture is just a wafer-thin veneer over anarchy. Music like The Fragile suggests that we are still trying to assimilate into popular culture the 'war-on-Self' worldviews unleashed by the nineteenth-century 'Masters of Suspicion' (Charles Darwin, Sigmund Freud, Friedrich Nietzsche). This 'assimilation gap' is evident in industrial music, which in the late 1970s was struggling to capture the mood of the Industrial Revolution and Charles Dickens, so the genre is ripe for further exploration of the scarred psyche. What the self-appointed moral guardians of the Herd fail to appreciate is that as the imprint baseline rises (reflective of socio-political realities), the kind of imagery prevalent throughout The Fragile and in films like Strange Days (1995), The Matrix (1999) and eXistenZ (1999) is going to get even darker. The solution is not censorship or repression in the name of pleasing an all-saving surrogate god-figure. No, these things have to be faced and embraced somehow. Such a process can only occur if there is space within for the Sadeian aesthetic that Nine Inch Nails embodies, and not a denial of Dark Eros. "We need a second Renaissance", notes Don Webb, "a rejuvenation of Culture on a significant scale". In other words, a global culture-shift of quantum (aeon or epoch-changing) proportions. The tools required will probably not come just from the over-wordy criticism of Cyber-culture and Cultural Studies or the logical-negative feeding frenzy of most Music Journalism. They will come from a dynamic synthesis of disciplines striving toward a unity of knowledge -- what socio-biologist Edward O. Wilson has described as 'Consilience'. Liberating tools and ideas will be conveyed to a wider public audience unfamiliar with such principles through predominantly science fiction visual imagery and industrial/electronica music. The Fragile serves as an invaluable model for how such artefacts could transmit their dreams and propagate their messages. For the hyper-alert listener, it will be the first step on a new journey. But sadly for the majority, it will be just another hysterical industrial album promoted as selection of the month. References Bester, Alfred. The Stars My Destination. London: Millennium Books, 1999. Eshun, Kodwo. More Brilliant than the Sun: Adventures in Sonic Fiction. London: Quartet Books, 1998. Van der Kolk, Bessel A. "Trauma and Memory." Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. Eds. Bessel A. van der Kolk et al. New York: Guilford Press, 1996. Nine Inch Nails. Downward Spiral. Nothing/Interscope, 1994. ---. The Fragile. Nothing, 1999. ---. Pretty Hate Machine. TVT, 1989. Citation reference for this article MLA style: Alex Burns. "'This Machine Is Obsolete': A Listeners' Guide to Nine Inch Nails' The Fragile." M/C: A Journal of Media and Culture 2.8 (1999). [your date of access] <http://www.uq.edu.au/mc/9912/nine.php>. Chicago style: Alex Burns, "'This Machine Is Obsolete': A Listeners' Guide to Nine Inch Nails' The Fragile," M/C: A Journal of Media and Culture 2, no. 8 (1999), <http://www.uq.edu.au/mc/9912/nine.php> ([your date of access]). APA style: Alex Burns. (1999) 'This machine is obsolete': a listeners' guide to Nine Inch Nails' The fragile. M/C: A Journal of Media and Culture 2(8). <http://www.uq.edu.au/mc/9912/nine.php> ([your date of access]).

Introduction The term ‘resilience’ is on everyone’s lips - from politicians to community service providers to the seemingly endless supply of self-help gurus. The concept is undergoing a renaissance of sorts in contemporary Western society; but why resilience now? One possible explanation is that individuals and their communities are experiencing increased and intensified levels of adversity and hardship, necessitating the accumulation and deployment of ‘more resilience’. Whilst a strong argument could made that this is in fact the case, it would seem that the capacity to survive and thrive has been a feature of human survival and growth long before we had a name for it. Rather than an inherent characteristic, trait or set of behaviours of particularly ‘resilient’ individuals or groups, resilience has come to be viewed more as a common and everyday capacity, expressed and expressible by all people. Having researched the concept for some time now, we believe that we are only marginally closer to understanding this captivating but ultimately elusive concept. What we are fairly certain of is that resilience is more than basic survival but less than an invulnerability to adversity, resting somewhere in the middle of these two extremes. Given the increasing prevalence of populations affected by war and other disasters, we are certain however that efforts to better understand the accumulative dynamics of resilience, are now, more than ever, a vital area of public and academic concern. In our contemporary world, the concept of resilience is coming to represent a vital conceptual tool for responding to the complex challenges emerging from broad scale movements in climate change, rural and urban migration patterns, pollution, economic integration and other consequences of globalisation. In this article, the phenomenon of human resilience is defined as the cumulative build-up of both particular kinds of knowledge, skills and capabilities as well as positive affects such as hope, which sediment over time as transpersonal capacities for self-preservation and ongoing growth (Wilson). Although the accumulation of positive affect is crucial to the formation of resilience, the ability to re-imagine and utilise negative affects, events and environmental limitations, as productive cultural resources, is a reciprocal and under-researched aspect of the phenomenon. In short, we argue that resilience is the protective shield, which capacitates individuals and communities to at least deal with, and at best, overcome potential challenges, while also facilitating the realisation of hoped-for objects and outcomes. Closely tied to the formation of resilience is the lived experience of hope and hoping practices, with an important feature of resilience related to the future-oriented dimensions of hope (Parse). Yet it is important to note that the accumulation of hope, as with resilience, is not headed towards some state of invulnerability to adversity; as presumed to exist in the foundational period of psychological research on the construct (Garmezy; Werner and Smith; Werner). In contrast, we argue that the positive affective experience of hopefulness provides individuals and communities with a means of enduring the present, while the future-oriented dimensions of hope offer them an instrument for imagining a better future to come (Wilson). Given the complex, elusive and non-uniform nature of resilience, it is important to consider the continued relevance of the resilience concept. For example, is resilience too narrow a term to describe and explain the multiple capacities, strategies and resources required to survive and thrive in today’s world? Furthermore, why do some individuals and communities mobilise and respond to a crisis; and why do some collapse? In a related discussion, Ungar (Constructionist) posed the question, “Why keep the term resilience?” Terms like resilience, even strengths, empowerment and health, are a counterpoint to notions of disease and disorder that have made us look at people as glasses half empty rather than half full. Resilience reminds us that children survive and thrive in a myriad of ways, and that understanding the etiology of health is as, or more, important than studying the etiology of disease. (Ungar, Constructionist 91) This productive orientation towards health, creativity and meaning-making demonstrates the continued conceptual and existential relevance of resilience, and why it will remain a critical subject of inquiry now and into the future. Early Psychological Studies of Resilience Definitions of resilience vary considerably across disciplines and time, and according to the theoretical context or group under investigation (Harvey and Delfabro). During the 1970s and early 1980s, the developmental literature on resilience focused primarily on the “personal qualities” of “resilient children” exposed to adverse life circumstances (Garmezy Vulnerability; Masten; Rutter; Werner). From this narrow and largely individualistic viewpoint, resilience was defined as an innate “self-righting mechanism” (Werner and Smith 202). Writing from within the psychological tradition, Masten argued that the early research on resilience (Garmezy Vulnerability; Werner and Smith) regularly implied that resilient children were special or remarkable by virtue of their invulnerability to adversity. As research into resilience progressed, researchers began to acknowledge the ordinariness or everydayness of resilience-related phenomena. Furthermore, that “resilience may often derive from factors external to the child” (Luthar; Cicchetti and Becker 544). Besides the personal attributes of children, researchers within the psychological sciences also began to explore the effects of family dynamics and impacts of the broader social environment in the development of resilience. Rather than identifying which child, family or environmental factors were resilient or resilience producing, they turned their attention to how these underlying protective mechanisms facilitated positive resilience outcomes. As research evolved, resilience as an absolute or unchanging attribute made way for more relational and dynamic conceptualisations. As Luthar et al noted, “it became clear that positive adaptation despite exposure to adversity involves a developmental progression, such that new vulnerabilities and/or strengths often emerge with changing life circumstances” (543-44). Accordingly, resilience came to be viewed as a dynamic process, involving positive adaptations within contexts of adversity (Luthar et al. 543). Although closer to the operational definition of resilience argued for here, there remain a number of definitional concerns and theoretical limitations of the psychological approach; in particular, the limitation of positive adaptation to the context of significant adversity. In doing so, this definition fails to account for the subjective experience and culturally located understandings of ‘health’, ‘adversity’ and ‘adaptation’ so crucial to the formation of resilience. Our major criticism of the psychodynamic approach to resilience relates to the construction of a false dichotomy between “resilient” and “non-resilient” individuals. This dichotomy is perpetuated by psychological approaches that view resilience as a distinct construct, specific to “resilient” individuals. In combating this assumption, Ungar maintained that this bifurcation could be replaced by an understanding of mental health “as residing in all individuals even when significant impairment is present” (Thicker 352). We tend to agree. In terms of economic resilience, we must also be alert to similar false binaries that place the first and low-income world into simple, apposite positions of coping or not-coping, ‘having’ or ‘not-having’ resilience. There is evidence to indicate, for example, that emerging economies fared somewhat better than high-income nations during the global financial crisis (GFC). According to Frankel and Saravelos, several low-income nations attained better rates of gross domestic product GDP, though the impacts on the respective populations were found to be equally hard (Lane and Milesi-Ferretti). While the reasons for this are broad and complex, a study by Kose and Prasad found that a broad set of policy tools had been developed that allowed for greater flexibility in responding to the crisis. Positive Affect Despite Adversity An emphasis on deficit, suffering and pathology among marginalised populations such as refugees and young people has detracted from culturally located strengths. As Te Riele explained, marginalised young people residing in conditions of adversity are often identified within “at-risk” discourses. These social support frameworks have tended to highlight pathologies and antisocial behaviours rather than cultural competencies. This attitude towards marginalised “at risk” young people has been perpetuated by psychotherapeutic discourse that has tended to focus on the relief of suffering and treatment of individual pathologies (Davidson and Shahar). By focusing on pain avoidance and temporary relief, we may be missing opportunities to better understand the productive role of ‘negative’ affects and bodily sensations in alerting us to underlying conditions, in need of attention or change. A similar deficit approach is undertaken through education – particularly civics – where young people are treated as ‘citizens in waiting’ (Collin). From this perspective, citizenship is something that young people are expected to ‘grow into’, and until that point, are seen as lacking any political agency or ability to respond to adversity (Holdsworth). Although a certain amount of internal discomfort is required to promote change, Davidson and Shahar noted that clinical psychotherapists still “for the most part, envision an eventual state of happiness – both for our patients and for ourselves, described as free of tension, pain, disease, and suffering” (229). In challenging this assumption, they asked, But if desiring-production is essential to what makes us human, would we not expect happiness or health to involve the active, creative process of producing? How can one produce anything while sitting, standing, or lying still? (229) A number of studies exploring the affective experiences of migrants have contested the embedded psychological assumption that happiness or well-being “stands apart” from experiences of suffering (Crocker and Major; Fozdar and Torezani; Ruggireo and Taylor; Tsenkova, Love, Singer and Ryff). A concern for Ahmed is how much the turn to happiness or happiness turn “depends on the very distinction between good and bad feelings that presume bad feelings are backward and conservative and good feelings are forward and progressive” (Happiness 135). Highlighting the productive potential of unhappy affects, Ahmed suggested that the airing of unhappy affects in their various forms provides people with “an alternative set of imaginings of what might count as a good or at least better life” (Happiness 135). An interesting feature of refugee narratives is the paradoxical relationship between negative migration experiences and the reporting of a positive life outlook. In a study involving former Yugoslavian, Middle Eastern and African refugees, Fozdar and Torezani investigated the “apparent paradox between high-levels of discrimination experienced by humanitarian migrants to Australia in the labour market and everyday life” (30), and the reporting of positive wellbeing. The interaction between negative experiences of discrimination and reports of wellbeing suggested a counter-intuitive propensity among refugees to adapt to and make sense of their migration experiences in unique, resourceful and life-affirming ways. In a study of unaccompanied Sudanese youth living in the United States, Goodman reported that, “none of the participants displayed a sense of victimhood at the time of the interviews” (1182). Although individual narratives did reflect a sense of victimisation and helplessness relating to the enormity of past trauma, the young participants viewed themselves primarily as survivors and agents of their own future. Goodman further stated that the tone of the refugee testimonials was not bitter: “Instead, feelings of brotherliness, kindness, and hope prevailed” (1183). Such response patterns among refugees and trauma survivors indicate a similar resilience-related capacity to positively interpret and derive meaning from negative migration experiences and associated emotions. It is important to point out that demonstrations of resilience appear loosely proportional to the amount or intensity of adverse life events experienced. However, resilience is not expressed or employed uniformly among individuals or communities. Some respond in a resilient manner, while others collapse. On this point, an argument could be made that collapse and breakdown is a built-in aspect of resilience, and necessary for renewal and ongoing growth. Cultures of Resilience In a cross continental study of communities living and relying on waterways for their daily subsistence, Arvanitakis is involved in a broader research project aiming to understand why some cultures collapse and why others survive in the face of adversity. The research aims to look beyond systems of resilience, and proposes the term ‘cultures of resilience’ to describe the situated strategies of these communities for coping with a variety of human-induced environmental challenges. More specifically, the concept of ‘cultures of resilience’ assists in explaining the specific ways individuals and communities are responding to the many stresses and struggles associated with living on the ‘front-line’ of major waterways that are being impacted by large-scale, human-environment development and disasters. Among these diverse locations are Botany Bay (Australia), Sankhla Lake (Thailand), rural Bangladesh, the Ganges (India), and Chesapeake Bay (USA). These communities face very different challenges in a range of distinctive contexts. Within these settings, we have identified communities that are prospering despite the emerging challenges while others are in the midst of collapse and dispersion. In recognising the specific contexts of each of these communities, the researchers are working to uncover a common set of narratives of resilience and hope. We are not looking for the ’magic ingredient’ of resilience, but what kinds of strategies these communities have employed and what can they learn from each other. One example that is being pursued is a community of Thai rice farmers who have reinstated ceremonies to celebrate successful harvests by sharing in an indigenous rice species in the hope of promoting a shared sense of community. These were communities on the cusp of collapse brought on by changing economic and environmental climates, but who have reversed this trend by employing a series of culturally located practices. The vulnerability of these communities can be traced back to the 1960s ‘green revolution’ when they where encouraged by local government authorities to move to ‘white rice’ species to meet export markets. In the process they were forced to abandoned their indigenous rice varieties and abandon traditional seed saving practices (Shiva, Sengupta). Since then, the rice monocultures have been found to be vulnerable to the changing climate as well as other environmental influences. The above ceremonies allowed the farmers to re-discover the indigenous rice species and plant them alongside the ‘white rice’ for export creating a more robust harvest. The indigenous species are kept for local consumption and trade, while the ‘white rice’ is exported, giving the farmers access to both the international markets and income and the local informal economies. In addition, the indigenous rice acts as a form of ‘insurance’ against the vagaries of international trade (Shiva). Informants stated that the authorities that once encouraged them to abandon indigenous rice species and practices are now working with the communities to re-instigate these. This has created a partnership between the local government-funded research centres, government institutions and the farmers. A third element that the informants discussed was the everyday practices that prepare a community to face these challenges and allow it recover in partnership with government, including formal and informal communication channels. These everyday practices create a culture of reciprocity where the challenges of the community are seen to be those of the individual. This is not meant to romanticise these communities. In close proximity, there are also communities engulfed in despair. Such communities are overwhelmed with the various challenges described above of changing rural/urban settlement patterns, pollution and climate change, and seem to have lacked the cultural and social capital to respond. By contrasting the communities that have demonstrated resilience and those that have not been overwhelmed, it is becoming increasingly obvious that there is no single 'magic' ingredient of resilience. What exist are various constituted factors that involve a combination of community agency, social capital, government assistance and structures of governance. The example of the rice farmers highlights three of these established practices: working across formal and informal economies; crossing localised and expert knowledge as well as the emergence of everyday practices that promote social capital. As such, while financial transactions occur that link even the smallest of communities to the global economy, there is also the everyday exchange of cultural practices, which is described elsewhere by Arvanitakis as 'the cultural commons': visions of hope, trust, shared intellect, and a sense of safety. Reflecting the refugee narratives citied above, these communities also report a positive life outlook, refusing to see themselves as victims. There is a propensity among members of these communities to adapt an outlook of hope and survival. Like the response patterns among refugees and trauma survivors, initial research is confirming a resilience-related capacity to interpret the various challenges that have been confronted, and see their survival as reason to hope. Future Visions, Hopeful Visions Hope is a crucial aspect of resilience, as it represents a present- and future-oriented mode of situated defence against adversity. The capacity to hope can increase one’s powers of action despite a complex range of adversities experienced in everyday life and during particularly difficult times. The term “hope” is commonly employed in a tokenistic way, as a “nice” rhetorical device in the mind-body-spirit or self-help literature or as a strategic instrument in increasingly empty domestic and international political vocabularies. With a few notable exceptions (Anderson; Bloch; Godfrey; Hage; Marcel; Parse; Zournazi), the concept of hope has received only modest attention from within sociology and cultural studies. Significant increases in the prevalence of war and disaster-affected populations makes qualitative research into the lived experience of hope a vital subject of academic interest. Parse observed among health care professionals a growing attention to “the lived experience of hope”, a phenomenon which has significant consequences for health and the quality of one’s life (vvi). Hope is an integral aspect of resilience as it can act as a mechanism for coping and defense in relation to adversity. Interestingly, it is during times of hardship and adversity that the phenomenological experience of hope seems to “kick in” or “switch on”. With similarities to the “taken-for-grantedness” of resilience in everyday life, Anderson observed that hope and hoping are taken-for-granted aspects of the affective fabric of everyday life in contemporary Western culture. Although the lived experience of hope, namely, hopefulness, is commonly conceptualised as a “future-oriented” state of mind, the affectivity of hope, in the present moment of hoping, has important implications in terms of resilience formation. The phrase, the “lived deferral of hope” is an idea that Wilson has developed elsewhere which hopefully brings together and holds in creative tension the two dominant perspectives on hope as a lived experience in the present and a deferred, future-oriented practice of hoping and hopefulness. Zournazi defined hope as a “basic human condition that involves belief and trust in the world” (12). She argued that the meaning of hope is “located in the act of living, the ordinary elements of everyday life” and not in “some future or ideal sense” (18). Furthermore, she proposed a more “everyday” hope which “is not based on threat or deferral of gratification”, but is related to joy “as another kind of contentment – the affirmation of life as it emerges and in the transitions and movements of our everyday lives and relationships” (150). While qualitative studies focusing on the everyday experience of hope have reinvigorated academic research on the concept of hope, our concept of “the lived deferral of hope” brings together Zournazi’s “everyday hope” and the future-oriented dimensions of hope and hoping practices, so important to the formation of resilience. Along similar lines to Ahmed’s (Happy Objects) suggestion that happiness “involves a specific kind of intentionality” that is “end-orientated”, practices of hope are also intentional and “end-orientated” (33). If objects of hope are a means to happiness, as Ahmed wrote, “in directing ourselves towards this or that [hope] object we are aiming somewhere else: toward a happiness that is presumed to follow” (Happy Objects 34), in other words, to a hope that is “not yet present”. It is the capacity to imagine alternative possibilities in the future that can help individuals and communities endure adverse experiences in the present and inspire confidence in the ongoingness of their existence. Although well-intentioned, Zournazi’s concept of an “everyday hope” seemingly ignores the fact that in contexts of daily threat, loss and death there is often a distinct lack of affirmative or affirmable things. In these contexts, the deferral of joy and gratification, located in the future acquisition of objects, outcomes or ideals, can be the only means of getting through particularly difficult events or circumstances. One might argue that hope in hopeless situations can be disabling; however, we contend that hope is always enabling to some degree, as it can facilitate alternative imaginings and temporary affective relief in even in the most hopeless situations. Hope bears similarity to resilience in terms of its facilities for coping and endurance. Likewise the formation and maintenance of hope can help individuals and communities endure and cope with adverse events or circumstances. The symbolic dimension of hope capacitates individuals and communities to endure the present without the hoped-for outcomes and to live with the uncertainty of their attainment. In the lives of refugees, for example, the imaginative dimension of hope is directly related to resilience in that it provides them with the ability to respond to adversity in productive and life-affirming ways. For Oliver, hope “provides continuity between the past and the present…giving power to find meaning in the worst adversity” (in Parse 16). In terms of making sense of the migration and resettlement experiences of refugees and other migrants, Lynch proposed a useful definition of hope as “the fundamental knowledge and feeling that there is a way out of difficulty, that things can work out” (32). As it pertains to everyday mobility and life routes, Parse considered hope to be “essential to one’s becoming” (32). She maintained that hope is a lived experience and “a way of propelling self toward envisioned possibilities in everyday encounters with the world” (p. 12). Expanding on her definition of the lived experience of hope, Parse stated, “Hope is anticipating possibilities through envisioning the not-yet in harmoniously living the comfort-discomfort of everydayness while unfolding a different perspective of an expanding view” (15). From Nietzsche’s “classically dark version of hope” (in Hage 11), Parse’s “positive” definition of hope as a propulsion to envisaged possibilities would in all likelihood be defined as “the worst of all evils, for it protracts the torment of man”. Hage correctly pointed out that both the positive and negative perspectives perceive hope “as a force that keeps us going in life” (11). Parse’s more optimistic vision of hope as propulsion to envisaged possibilities links nicely to what Arvanitakis described as an ‘active hope’. According to him, the idea of ‘active hope’ is not only a vision that a better world is possible, but also a sense of agency that our actions can make this happen. Conclusion As we move further into the 21st century, humankind will be faced with a series of traumas, many of which are as yet unimagined. To meet these challenges, we, as a global collective, will need to develop specific capacities and resources for coping, endurance, innovation, and hope, all of which are involved the formation of resilience (Wilson 269). Although the accumulation of resilience at an individual level is important, our continued existence, survival, and prosperity lie in the strength and collective will of many. As Wittgenstein wrote, the strength of a thread “resides not in the fact that some one fibre runs through its whole length, but in the overlapping of many fibres” (xcv). If resilience can be accumulated at the level of the individual, it follows that it can be accumulated as a form of capital at the local, national, and international levels in very real and meaningful ways. 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IntroductionEmpathy: the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another, either in the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also: the capacity for this. (Merriam-Webster, “Empathy”)Compassion: sympathetic consciousness of others’ distress together with a desire to alleviate it. (Merriam-Webster, “Compassion”)After thirty years of being a vegetarian, my eyes were opened to the inherent cruelty in animal-use industries. I became vegan and spoke out on these issues at animal rights events, rallies and ethical leadership forums. My private psychology practice attracted a significant number of vegans who presented with symptoms of anxiety and depression. However, unlike many of my non-vegan clients who were unclear as to what caused their symptoms, vegans reported it as being directly related to their discovery of systematised animal misuse in society. It was as if they had extended their compassion beyond their own species.Despite these issues being increasingly discussed in open circles, this extension of compassion seems to be limited to veganism. Why is veganism increasing as a compassionate centre, with animal social justice being at its core? Drawing on key emotional experiences of vegans, based on a survey conducted in 2018 and observational data from a private psychology practice, this article explores the experiences of compassion and empathy of vegans, and the impact such experiences can have on social change.The Increase in VeganismVeganism has noticeably increased over the past decade, with greater public debate in the media. A 2016 Roy Morgan poll indicated that the number of strict vegetarian adults in Australia was 2.1 million; an increase of nearly half a million people over four years, and likely to grow (Roy Morgan). Internationally, veganism was the biggest trend of 2018, with over three times the level of interest online as “vegetarian” or “gluten-free” (The Vegan Society).I believe there are a number of reasons for this, including greater awareness through social media, increased social mobility, and people becoming aware of international practices (Oberst). Photos and videos of animal suffering are more easily accessible via mobile devices, and can be shared at a faster rate than mainstream media could traditionally share news (Forgrieve). Small budget Indie films have also shared unknown information with the public, such as Earthlings, Dominion, Cowspiracy, and Kangaroo. In addition to this, I believe there is a greater propensity for people to challenge authority and previous direction from doctors or politicians in what is known as “the era of respect” (Mowat, Corrigan, and Long).These circumstances and more have led to an increase in people making more informed, kinder choices with regard to veganism; suggesting the opening of a new era of compassion beyond one’s own species. However, living in a world where the majority of people’s consumer choices facilitates animal abuse behind closed doors, the vegan is left struggling with “the burden of knowing”; knowledge of the facts of animal mistreatment and the inability to change it or successfully induce others to acknowledge it (Mann, Vystopia).Case Study ResearchBetween 2013 and 2018 I held individual psychological counselling sessions with over 100 self-selected vegans. For these case studies, the definition of “vegan” means someone who has chosen to live their life underpinned by the philosophy of the non-use and non-exploitation of animals and informs what they eat, wear, use and are involved in. These individuals reached out to me because of the trauma they reported experiencing since learning of the ubiquitous nature of animal cruelty in society. They claimed to feel more comfortable with a vegan professional who they felt understood their anguish.From these sessions, using the qualitative research methodology of hermeneutics (Rennie), I began to notice a pattern relating to the nature and enormity of the typical vegan’s distress. Almost every vegan who came to see me presented with symptoms related to their awareness of the systemised cruelty towards animals. Their distress was compounded when they shared this information with their friends and family, whom they were sure would be equally upset by it. Instead, many people responded with indifference, criticism, and anger, saying that everyone has a right to choose what to eat. These feelings of frustration and powerlessness left them unable to reconcile competing beliefs; that the people they loved were capable of turning their eyes away from the suffering their consumer choices were financing. The typical symptoms they reported included (fig. 1):Complicated griefMental anguishDepressionAnxietySelf-medicationAnger and despairSelf-harmSuicidal thoughtsHopelessnessLonelinessPost-Traumatic Stress Disorder (PTSD)Fig. 1: Typical symptoms reported by vegans in individual counselling sessions, 2013–2018.After over 1,300 hours of one-to-one sessions with vegans around the world, plus anecdotal stories from vegans I met at numerous events, I came to believe that the vegan’s pain is unique to being vegan and warrants a specific definition.It is imperative to me that vegans do not become labelled as mentally ill or chronically dysfunctional, for which the only solution is medication. As a fellow sufferer of the “burden of knowing”, I wanted to create a term to validate our experience and avoid medicalising our plight. Only then can the vegan’s experience be examined from a humane perspective and solutions be found to help us. Then, we can become part of the rising tide of social action that says human superiority and animal abuse is unacceptable. Because I believe that this experience and associated symptoms are existential in nature, I called this “Vystopia” (Mann, Vystopia).VystopiaThe Existential crisis experienced by vegans, arising out of an awareness of the trance-like collusion with a dystopian world and the awareness of the greed, ubiquitous animal exploitation, and speciesism in a modern dystopia. (Mann, “Suffer”)Vystopia is the anguish a vegan feels, knowing about the systematised cruelty towards animals in society, and the further distress they experience with the unconscious collusion of non-vegans, and their resistance or criticism of this information. Many of my clients experienced a range of symptoms of vystopia (fig. 2): Feelings of alienation from non-vegansMisanthropyGuilt over past consumption of animalsGuilt that they are not doing enough to save animalsInability to enjoy normal aspects of lifeFrustration with non-vegans who don’t ask more questionsAnger with the “burden of knowing”Powerlessness when health professionals tell them “it’s normal”Fig. 2: Symptoms of VystopiaMisdiagnosis of the Vegan’s ConditionMany doctors have referred patients to me for mental health symptoms of eating disorders, social adjustment disorder, and self-harm. It is my opinion that vegans referred to me with these symptoms do not suffer from traditional eating or self-harm disorders.As I learned from working in a psychiatric teaching hospital in the UK, clients with these conditions are often deeply unaware of the reasons influencing their symptoms. Their symptoms become an outward sign of hidden or unconscious distress which is too painful to confront directly. The vegans sent to me are deeply distressed due to the horror they’ve witnessed or now know about in the animal industries.I discovered that regularly viewing graphic videos of animal abuse was linked with vegan clients diagnosed as having self-harm tendencies (Klonsky). They view these as they feel guilty if they don’t know about all aspects of the animal’s suffering. It’s only by knowing all the details that they can be informed and act to change it. Vegan clients who have told their doctors they “can’t eat around people who are consuming animals” are often diagnosed as having eating disorders, although they lack the typical medical symptoms of eating disorders. While it is possible for vegans, like anyone else, to suffer from these conditions, I believe that many clients have been misdiagnosed. For many, their symptoms are indicative of a normal, feeling human’s way of dealing with vystopia: The truth is that it is not a pathology, but the distress a vegan feels when they look at the state of the world and the cruelty and suffering and it’s an absolutely rational response any feeling human being should feel; a dystopian reaction to what they are seeing. (Klaper)Survey ResearchBetween February and July 2018, I conducted an anonymous online survey of 820 vegans. The survey comprised 26 multiple-choice questions covering 7 main areas:How long someone has been veganLength they have experienced vystopiaWhen vystopia was most experiencedWhere people seek help for vystopiaWhat they do to reduce symptomsFamily and relationships where significant others are not veganWhat support is most needed to help vystopiansResultsWhilst an in-depth analysis of the results is outside the scope of this article, some of the key responses are as follows (figs. 3–6):How long have you been vegan?1–5 years48%Less than 6 months16%6–12 months14%5–10 years12%10 years plus10%Fig. 3: Length of time as vegan.How long have you suffered from vystopia?1–5 years39%5–10 years21%6–12 months15%Less than 6 months13%10 years plus12%Fig. 4: Length of time suffering from vystopia.When do you most experience vystopia?Others around you eat animals79%Seeing images of animal cruelty78%Other people refuse to hear about animal cruelty78%Grocery shopping69%People laugh at you for being vegan56%Family celebrations55%Holidays40%At work events39%All the time37%When away from vegan friends30%Other8%NB: Participants invited to tick all that apply Fig. 5: When vystopia is experienced.What do you do to reduce your vystopia?Remove yourself from the world58%Increase animal advocacy55%Talk to friends34%Self-medicate (e.g. alcohol, drugs, food)24%Other16%See a doctor2%Fig. 6: Actions taken to reduce vystopia.Explaining the Differences in Adoption of VeganismWhy do some people extend their compassion towards animals whilst others are unaware of the need to do so, or believe it is anthropomorphic or sentimental? Research is needed to examine this more, but my own research and anecdotal experience suggests some factors:Social ConformityMany people are strongly influenced by what they perceive as socially normal (Mallinson and Hatemi). Cultural and family traditions, media, and community behaviour all influence the food and lifestyle choices of society. Most people are unaware that their consumer choices play a role in the mistreatment and abuse of animals.Social conditioning influences whether people choose to investigate new information further or continue with the status quo for the sake of fitting in. The need to fit in creates a social trance whereby people continue to collude with animal cruelty through their inaction, and in fact their willful ignorance means they are not likely to change their actions, as they don’t know any differently.The vegan is one who has chosen to find out the truth about animal exploitation and extend their compassion towards other species by abstaining from anything related to animal abuse.Personal and Social Defense MechanismsSimilar to social conformity, the concept of being “different” from the perceived norm is enough for many people to continue with their actions, regardless of the consequence for animals. Similarly, those who are suddenly privy to new information may feel judged by the messenger, and resistance is easier than change. The vegan is one who chooses to adjust their actions, despite the judgement or ridicule which may accompany it.Personality VariablesOn the Myers-Briggs Type Indicator (Myers and Myers), my anecdotal experience suggests that individuals with preferences for “feeling” over “thinking” are more likely to become vegan. The vegan community consists of many different personality types, with those who are strong “feeling” types more inclined to display empathy and empathetic action.Avoidance of Existential Anxiety When a person’s understanding of the world is challenged, this can create anxiety, where one is compelled to ask, “What else don’t I know?” If animal cruelty can occur at such a widespread rate—with most of society oblivious to it—what else is going on behind closed doors? For some, the reality of facing the truth can create enough angst that they will resist knowing and changing. The vegan may still experience such angst, but is compelled to change for the sake of the animals. Differing Capacity to Encompass Novel IdeasIdeas which vary from a widely believed ideology are often rejected, simply because the new idea is too radical to believe or comprehend. Consider the Law of Gravity or the concept of germs, both initially shunned by experts. Some people are more willing to delve into a new concept and explore the possibilities which come with it. Others are firmly tied to conformist ideology and will only jump on the bandwagon once others are driving it.Differing Levels of ConsciousnessIn the original book on Spiral Dynamics, Beck and Cowan talk about the magnetic forces that attract and repel individuals, the webs that connect people within organisations, and influence the rise and fall of nations and cultures. The book tracks our historic emergence from clans and tribes to networks and inter-connected networks. It identifies seven variations on how change occurs in individuals, society and leadership.Its relevance for veganism is in appreciating that there are different levels of consciousness in society. For example, a vegan passionate about the ethical treatment of animals would be faced with resistance from a hunter with a more tribal level of consciousness, according to the Spiral Dynamics model. It would be like two people from different planets communicating. Another example would be a community outraged by the influence of veganism on local employment, as demand for dairy reduces. By understanding where other people or groups are coming from, we can adapt the way in which we communicate. If vegans talk ethics and non-speciesism to people focused primarily on job security, they will face resistance.Tipping PointsIn marketing, the uptake of products and services follows a certain pattern. For example, in the 1990s, few people believed that the mobile phone market would explode to such a point. The same goes for changes in collective beliefs and ideas in society, such as the early protagonists for the Abolition of Slavery. These early innovators and adopters faced enormous resistance by those who benefited from the trade. As the movement gathered momentum, it reached what Gladwell has called the “Tipping Point”, “the moment of critical mass, the threshold, the boiling point” (12). As Gladwell stresses here, “ideas, products, messages and behaviours spread like viruses do” (7).In The Empathetic Civilization, Rifkin discusses society being wired for empathy. This occurs when the neurons in the brain mirror those of people around them, and can be likened to the psychological concept of “entrainment”. This phenomenon suggests that vegans have the ability to influence others through showing empathy and compassion.Increasingly, teenage vegans are referred to me who say, “I just had this awareness and know it is wrong to eat animals”. Many of them hadn’t seen anything on veganism or spoken to anyone about animal exploitation. I believe that this is an example of what Jung has called the “Collective Unconscious”; the structures of the unconscious mind which are shared among beings of the same species. This is encouraging for vegans who often feel helpless and cannot see how a vegan world will happen in their lifetime.ConclusionThose who are vegan for ethical reasons appear to feel compelled to take action to end animals’ plight. This may be because of the ubiquitous nature of the problem, but also because other people’s non-veganism is contributing to their vystopia.The extended compassion of vegans leaves them feeling depressed, wondering how enough people are going to change in order for veganism to become the new norm. The concept of entrainment is an encouraging one for vegans, reminding us of the importance of playing our part in being the example we want others to “entrain” to.It is my experience that empathy alone will not alleviate vystopia for these ethically-driven vegans. Vystopia can only be alleviated through action. A person may feel compelled to take action to end the suffering of refugees, children, the homeless and when they tell people, their efforts are applauded. The vegan who changes their everyday consumer choices to end animal suffering is often met with resistance, derision or criticism, as the non-vegan insists they have choice or that animals are inferior to humans. Another person may disagree with animal cruelty and yet refuse to change their consumer habits which finance the cruelty. One’s food choices are powerful political actions, and disagreeing with animal cruelty yet eating animals fuels the vegan’s vystopia. By shifting our focus from how awful the world is to taking action every day to mirror the vegan world we seek, we are creating a new norm to which others will entrain.With the increase in veganism trending upwards, the changes we are seeing across the world might mirror our compulsion to act. While the depth of animal empathy and vystopia is full of real anguish, I believe it also provides what we need to propel the world towards a vegan norm.ReferencesBeck, Don Edward, and Christopher Cowan. Spiral Dynamics: Mastering Values, Leadership and Change. New York: Wiley-Blackwell, 2005.Cowspiracy: The Sustainability Secret. Dirs. Kip Anderson and Keegan Kuhn. Appian Way, A.U.M. Films, First Spark Media, 2014.Dominion. Dir. 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