Nurture in a time of crisis

December 17, 2021

Jenny Brown

 

The topics of nurture and mental health are broad and complex. They are deeply personal issues that touch everyone in one way or another, whether directly ourselves, or in family, work, or study contexts.

***

As a clinician, supervisor, trainer, and researcher, I aim to encourage you to think about what help helps? What sort of nurture promotes the growth and learning for life of a person or group of people? What kinds of help are on offer, and are they helping growth and development or inadvertently impeding it? Are we fully accessing the sources of nurture available in our communities and families?

Note that while I’m questioning mainstream treatment services and efficacy, I’m not in any way minimising the debilitating effects of mental unwellness for people who suffer. Nor am I disregarding the knowledge and dedication of practitioners in the field who I value as colleagues and empathise with in the complex demands of providing service.

I also want to declare my theoretical bias. I work in the Systems approach developed by psychiatrist and researcher Dr Murray Bowen. The key features of this approach are that:

• Relationships are central; they’re a force for nurture but can also impede growth
• People are on a continuum of relational sensitivities and also a continuum of managing stress and anxiety
• Individuals grow resilience by working to manage themselves less reactively in their real life relationships
• The practitioner’s posture is to work with someone side by side, rather than as an expert coming in to ‘fix’ a helpless patient

What follows is a broad sweep of general mental health (MH) problems rather than specific diagnoses. I focus more on the most widespread symptom categories of affective and anxiety presentations.

I. Mental health landscape

What is the current state of mental health in Australia (and globally)? Are we truly in a crisis, or is there just more understanding about MH issues than in the past and more services available, along with less stigma and more openness to accessing help? What are the current trends in diagnosis and treatment? And is there anything missing that might help? 

Is there a crisis?

Looking at pre-pandemic data provided by the World Health Organisation (2007-2017),[1] there are certainly indications that there is a mental health crisis beyond other hypotheses or explanations. From 2007 to 2017, there was a 13% rise in MH conditions and substance abuse disorders. About 20% of the world’s children and adolescents have a MH condition, with suicide the second leading cause of death in 15–29-year-olds.

In Australia, the National Survey of Mental Health and Wellbeing conducted by the ABS (summarised every 12 years—this one in 2008) showed that around 25% of people in the 16-24 and 25-34 age groups presented with symptoms in 12 months, compared to only 5.9% in the 75-85 age bracket. The most prevalent were anxiety disorders (M: 10.8%, F: 17.9%), followed by affective disorders (M: 5.3%, F: 7.1%), and substance abuse disorders (M: 7%, F: 3.3%).[2]

From 2009-10 to 2019, the number of Australians who accessed Medicare subsidised MH services doubled from 1.4 million to 2.7 million.[3] Such substantial increases in MH presentations make it clear that we are indeed in a crisis.

What about the ‘shadow pandemic’—the impact on MH of COVID-19, with its multiple societal, family, and individual stressors? The currently available data indicates that the prevalence of MH conditions during the pandemic is higher than before, but it’s not straightforward. One clear thing is that a lot of the issues that have emerged under the stress of the pandemic were present already; that is, they were amplifications of pre-existing vulnerabilities.

Not all parts of the population are impacted in the same way. There is evidence that being young and being female are risk factors for high levels of distress and loneliness.[4] A study done in the UK indicates women, young people, and those living with young children were the most negatively impacted during the pandemic. Interpersonal violence and marital breakdown were also amplified.[5] As yet, there is no evidence of an associated rise in deaths by suicide in the general population, with the exception of adolescents.[6]

Diagnosis and treatment trends

Up to the end of the 19th century, mental health care was predominantly about treating psychoses and took place in asylums. Counselling was the domain of teachers or clergy and focused on character development— particularly moral character. The 20th century saw the beginning of treatment for patients with the milder neuroses and personality disorders. Talking therapies were introduced by the likes of Freud and Jung, and MH professions were created and quickly proliferated.

The Mental Hygiene movement coincided with medicine starting to broaden its scope beyond physical illness to psychosocial issues, and we saw the beginnings of the medicalisation of MH. In the late 1950s, effective anti-psychotic medications arrived on the scene, and resulted in the closing of many large psychiatric hospitals, and the expansion of community services.[7]

The 1990s saw evidence-based treatments like Cognitive Behavioural Therapy (CBT) grow in popularity. In recent decades, the trend I have observed in service delivery has been towards private practice, the rise of NGOs in the field, and online telehealth and treatments. Family therapies also emerged (especially in the 1970s) but have not entered the mainstream as the nature of family therapy makes it difficult to evaluate and produce the evidence base required for attracting funding.

In the past decade in Australia, funding to public and NGO MH services doubled, with the outstanding growth being in acute care, psychiatric units, and community services. The number of MH professionals also burgeoned over this time (8.3% more psychiatrists; 7% more MH nurses; 8.9% more psychologists). The data also tells us there was a massive rise in GP delivery of MH care, and that in over 61% of GP presentations, scripts were written, predominantly for antidepressants.[8]

Recent developments, then, have continued and accelerated the trends in MH diagnosis and treatment that have been evident throughout the 20th century: increasing professionalisation and medicalisation.[9] There has been a shift away from seeking nurture within families, communities, and churches, towards seeking it in the offices of medical and MH experts—doctors, psychologists, psychiatrists, and therapists.

Is where we’re going taking us towards the best nurture possible?

What’s missing?

In a way, it’s easy to put all our resources into researching and dealing with mental illness and its distressing symptoms, but I’d like to draw attention to what’s missing from MH research.

One omission is the consideration of protective factors—factors that lower the risk of developing mental illness in the first place.

We saw that the pandemic had an intensifying effect, with stress exacerbating pre-existing vulnerabilities. But it also revealed that having a positive pre-pandemic home environment mitigated the impact of COVID- related stress impacts.[10]

Also telling was a survey of 1000 Australians[11] which found that 70% of participants reported having experienced at least one positive effect of the pandemic. The three top positive effects reported were:

1. Having the opportunity to spend more time with family
2. Having greater flexibility in working arrangements
3. Appreciating having a less busy life

In these experiences of the pandemic, we can find clues about what is central to human wellbeing. These protective factors highlight the value of relationships, work-life balance, stable family life and connection to nature.

Another neglected research area is the variety of ways people might recover from mental illnesses apart from medical or professional interventions. Despite the many ways that have been suggested to address youth depression and anxiety, for example, less than 10% of research in the area evaluated interventions not involving a professional. Yet exercise, community engagement, and engagement with nature are all inexpensive and readily available treatment options that could be evaluated quite straightforwardly.[12]

Treatment outcomes for depression[13]

• 54% of adults show improvement after antidepressant medication
• 35–40% of adults show improvement after a pill placebo in randomised trials
• 62% of adults show improvement after psychotherapy (66% in CBT)
• 43% of adults show improvement in care-as- usual control groups of psychotherapy trials
• 53% of adults with untreated depression show improvement in 12 months

This is particularly concerning given that, despite significant ongoing research efforts to refine treatments in recent decades, improvements in efficacy are questionable. 

Another factor that is beginning to be more widely recognised is the inadequacy of diagnostic categories in MH. An article published in Nature notes that biologists have been unable to find any genetic or neuroscientific evidence to support the breakdown of complex mental disorders into separate categories.[14] The National Institute of Mental Health Research Domain Criteria (RDoC)[15] shows that the research domain in MH cannot use diagnostic categories effectively because they don’t adequately reflect the complexity of the human condition. They claim it’s vital to adopt dimensional conceptualisations and move away from arbitrary diagnoses to reflect the full spectrum of mental health and illness. This is one positive sign of a movement towards humanising, rather than medicalising, human struggles, although it does not include the family domain of human functioning.

Finally, the significant redirection from nurture in family and communities to nurture in the offices of doctors and other professionals means that these elements are usually missing from the current MH treatments on offer.

Religious communities are an example of communities that, in the past, have had a key role in supporting people through the struggles of life. If we take the Judeo-Christian tradition and look at the relational themes of nurture in the Bible, we can reflect on the non-medicalised themes of nurture.

Biblical nurture is expressed

• By parental instruction, care and example (Deuteronomy 4:9)
• By the caring attitude and life example of elders (Proverbs 4:3-4)
• By the caring attitude of fellow believers (1 Thessalonians 2:7)
• By appropriate teaching (1 Peter 5:2-3)
• By encouraging spiritual growth (Ephesians 4:15)

Humans are social creatures for whom relationships are of central importance. Yet these have been factored out of MH treatment. By sending people out to get ‘fixed’ before they return to the community, are we essentially saying people with MH difficulties have no valid place in the life of the community in question? What are the ramifications of removing the nurture of human struggles from its relational context?

II. Back to basics

I believe it is helpful to take the medicalised complexity out of the MH discourse. So let’s look at the essentials of MH issues linked to the human stress response.

Anxiety is a fear response to threat, and stress is the fear-activated mobilisation of the body’s resources to meet the threat. The release of cortisol and other stress hormones affect the entire body, including cognition and mental processes.

This is a natural process that mobilises the organism to meet the challenge. We’ve all heard of the fight/flight and freeze responses to stress, but the list can be expanded to include being fractious, fretting, and fixing.[16] Note that these are often embedded in relationships— they don’t just affect the person directly under stress. 

A real threat to resources, social position, health, or survival warrants a stress response. But humans have a unique problem: our imagination. We respond to stressors beyond ‘what is’ to ‘what if’. We can easily imagine something to be a threat when it isn’t, or overestimate a real threat.[17]

For most people exposed to a threat or severe challenge, the stress response will reset itself to a normal baseline within a period of time. MH problems arise when this reset doesn’t occur. Persistent levels of tensions lead to:

• Hypersensitivity (exaggerated attunement to external threat or negative perception)
• Personalisation (taking external cues personally as if negatively directed at self)
• Overreaction (an emotional response amplified beyond the circumstance)
• Chronic anxiety symptoms (continually on edge and alert to negative input)

The aim of nurturing good MH from a family systems approach is to develop agency, resilience and self-efficacy, and avoid interventions that encourage passivity, helplessness, or dependency. It’s of key importance, then, as we nurture ourselves and think about nurturing others, to learn (and help others learn) to attend to the threat response, and to grow more self-regulation in the context of significant relationships.

The more we attend to our body’s stress responses and practise skills to bring down the agitation, the more choice we develop between attending to our feelings or our thinking. We can have our feelings and emotions without them having us.[18]

Nurturing our capacities for managing fear, stress, and other strong emotions, is at the core of better MH. This needs to happen in the context of relationships and communities, which are the best laboratories for growing resilience. Avoidance of uncomfortable relationships reduces our capacity to manage our sensitivities.

The goals of family systems interventions are to:[19]

1. Function rather than fix. Approaching an intervention as an opportunity to think about improving our functioning in our circumstances takes us down a different path to expecting it to fix a problem.
2. Treat clients as persons not patients. When people give up their own capacity to problem solve, they are left to either blindly depend on others or to blame and criticise others when their advice does not work. But the aim of interventions is not to create dependent followers or reactive blamers, but people who have agency and resilience. The ‘expert’ should not work harder than the client; rather, there should be a partnership that focuses on the client’s capacities to help themselves, not their disabilities.
3. Keep in contact, not cut off. The more people under stress isolate from relational networks while seeking help, the more vulnerable they are to relapse when they return to those contexts. An empathic professional can provide a comfort zone that is not in keeping with real life relationships. This can lead to reduced tolerance for everyday relationship disruptions.

We’re all on a continuum of coping capacity. By observing ourselves in relationships, we come to understand our response patterns to stress. A challenge is to stop seeing ourselves as damaged. Instead of focusing on trauma and adversity, we begin to see choice and agency in how we are in different relationships and circumstances.
 

III. Mental health in communities

What does all this mean for purpose-driven communities, such as churches, schools, service clubs, residential colleges, and some workplaces, and those responsible for MH within those communities? In what follows l will refer primarily to churches, but what is said will largely be generalisable to other community contexts. 

Not surprisingly, the MH crisis facing society in general is also reflected in church communities.[20] So, too, is the dynamic of professionalisation of MH assistance and the corresponding danger of intimidation and perceived inadequacy among non-expert carers. As a result, leaders can be quick to outsource problems rather than seek to address them using resources present in the community.

Note, again, that I am not advocating avoidance of professional help. On the contrary, professional help that supports resilience may be of great value when warranted. But carers shouldn’t be intimidated into jumping straight to outsourcing to an expert or assume that they will be unable to help because they are not professionals.

One of my aims here is to help churches and other communities identify and employ their natural nurturing capacities in assisting people to manage the struggles of life.

Belonging

There is considerable literature on the beneficial effects of community belonging. One investigation of the relationship between Christianity and wellbeing concluded that nurturing, non-punitive religion is associated with mental and physical health and that active participation in church activities that enhance the member’s social support system can be beneficial.[21]

Having a sense of belonging also promotes wellbeing. The 2001 and 2006 National Church Life Surveys (Attender surveys) indicate that around 80% of church attendees surveyed report a sense of belonging to their church community.[22] Communities with purpose provide a depth of connection that enhances wellbeing beyond what superficial social gatherings offer. In addition, the regular pattern of gathering together in small and larger groups provides a relationship routine that can be steadying. 

Highly complex relational systems like churches have substantial nurturing capacity. Yet, at the same time, they involve relational sensitivity patterns that can play out in ways that undermine nurturing. These sensitivities can be categorised as follows:[23]

• Expectations—what are members’ expectations? Are they being met?
• Sensitivity to attention—who is getting attention in the group, and who is missing out?
• Sensitivity to approval/disapproval—what are the patterns of criticism and praise?
• Sensitivity to distress in others

These sensitivities often undermine the nurturing capacity of communities by injecting anxieties into relationship interactions. Confused communications ensue as people react to any perceived loss of status in church relationships. The result is that relationships can become draining rather than enhancing.

Caring

I asked earlier, what kind of help helps rather than hinders growth? The role of the counsellor or pastoral carer in the Bowen systems approach is not that of the expert to a patient but of side-by-side exploration. The aim is to help people engage in problem-solving, not take their burdens. To learn to tolerate and regulate stress, not remove it. In the long run, this will help the struggler more by building protective resilience.

Variations in maturity

Carers are wise to recognise that not everyone has the same coping capacities and not to make a project of changing people. Each individual will be in different places on a complex multidimensional spectrum, each with their own starting points and struggles, partly determined by the ‘hand that’s dealt them’ and in which they had no say. Tim Keller, in The Reason for God, points out

Good character is largely attributable to a loving, safe, and stable family and social environment. Instead, many have had an unstable family background, poor role models, and a history of tragedy and disappointment. As a result, they are burdened with deep insecurities, hypersensitivity, and a lack of self- confidence. They may struggle with uncontrolled anger, shyness, addictions, and other difficulties as a result.[24]

Different family backgrounds, experiences, and genetic predispositions mean people are all in different places as they strive towards more maturity. We all bring differing degrees of relationship sensitivities from our families of origin. Therefore, a helper needs to respect the variations in each person’s resilience and not impose unrealistic functioning standards. 

Avoiding burnout

Employing a side-by-side ‘coaching’ model offers benefits for the person suffering and protects counsellors against burnout. Burnout is a significant problem for those whose role in ministry is to provide pastoral care. The 2011 National Church Life Survey reported that 23% of Protestant pastors experienced burnout. A further 56% were classified as ‘borderline to burnout’ and deemed potential candidates for burnout if current issues were not resolved.[25] Multiple factors are contributing to these statistics, including the sheer number of people ministers provide care to, but one factor is the stress involved in seeing one’s role as that of rescuer.

Tara Stenhouse has written helpfully about her own experience of moving from the role of ‘rescuing pastor’:

Caring as a rescuer leaves me more overwhelmed and stuck, feeling quite burdened by my pastoral role, wearing the anxiety of the suffering of others in a way that lingers after I have left work.[26]

to that of ‘side-by-side pastor’

I am less anxious, I am clearer about what my role is, and I am more confident of what I am trying to do. I have come away refreshed and encouraged. I have not aimed to solve their problem, rather to listen, acknowledge their pain, and ask good questions.[27]

The pattern of over- and under-functioning is present in both families and non-family systems. The overfunctioner manages underlying insecurities and stress by thinking, feeling and doing for another while the underfunctioner steadies themselves through allowing another to take over their responsibilities and upsets. This is distinct from mutual service to each other.

‘Over-helping’ and ‘over-venting’ may temporarily make people feel important or valued but can leave people burnt out and confused in the longer term. In quite subtle ways, what we think is in service of others can unknowingly be in service of ourselves.[28]

Detrimental relationship patterns

An awareness of the pitfalls in human relationships and the predictable patterns that we as immature humans get caught up in, and the consequent ability to make conscious adjustments to those patterns, is a valuable gift to the flourishing of a group. We’ve already seen a couple of these growth-hindering patterns: using avoidance as a means to stress reduction is one; another is the reciprocal dance of under- and over-functioning in relationships.

Forming triangles is another common detrimental pattern. It occurs when two people experience conflict, and a third person comes in (voluntarily or by invitation) to reduce the stress by aligning with one of the original pair, providing a sympathetic ear for complaints. While this initially reduces the tension, it also detours the original disputants from resolving their conflict. Triangling can easily spread, with interlocking triangles forming as more and more allies are enlisted. What starts as a conflict between two members can snowball into a confused tension that affects the whole community.

Lauren Errington notes how easily a caring person can unwittingly initiate a triangle:

Under the auspice of helping, we can be quick to become involved in other people’s affairs unnecessarily. We see strife between others, and we are hasty in our intervention: a smiling interruption to break the tension, a quick word after church, a follow up phone call or email to see that things are okay. The difficulty with triangling is that these interventions are often welcomed—no-one likes tension! ... But what if our ‘helping’ actually inhibits the other person from finding the resources themselves to solve the problem?[29]

The challenge here is for the people experiencing the conflict to keep it in the original relationship, tolerate the tensions and difficulties, and for caring outsiders to allow space for this and not get caught in complaints or alliances.

However, an objective third party can have a valuable role in diffusing conflict between two people. This person avoids getting caught up in the content of the debate. Instead, they tune in to the process – how the disputants have been addressing their conflict and the effect of this. A calm, neutral third party can help each party see how they’re approaching the tension and whether this can reveal ideas for doing better.

Self awareness

If you have a pastoral/caring role in a community, one of the most helpful things you can do is be aware of your own sensitivities and work on your maturity gaps. The aim is to enhance your capacity to be in calm and meaningful connection with others, while also sustaining your goal-direction and meeting your responsibilities. Maintaining a mature balance of connection and separateness in relationships can be one of the best ways of serving other people and being a resource for them.

However, work on our own maturity gaps must be done with an eye to the constant temptation of self-focus. Dr Murray Bowen— not a church-goer—was aware that there was a good dose of narcissism in all of us. Those of us coming from a Christian faith perspective recognise in ourselves the sinful capacity of self-interest to hijack all our endeavours. When this happens, we need to be ready to repent, be aware of the impact our self-focus can have on others, and apologise when we need to.

***

Communities have a great capacity to promote nurture, but also to generate stress and anxiety. Bowen theory offers strategies for growing maturity in community members to enhance nurturing opportunities and reduce the effects of tension and conflict. Working on these can reduce burnout in pastoral carers, and contribute to communities providing a place of calm, gracious belonging for their most fragile members.

Like other shared-purpose communities, Christian faith communities have the capacity to offer enormous mental health benefits, but also need to be on guard against burnout and detrimental relationships, and aware of member sensitivities. Yet it needs to be noted that Christian communities offer much more than the human relationship benefits of a shared purpose group. Being a Christian ‘is not just membership in a new religious society. ... [W]e become sharers and participators in His [Jesus’] life and in all the blessings that come from him.’[30]

Conclusion

My aim in this paper, and the lecture series from which it was taken, is to open up new conversations about our current mental health neediness and treatment systems to ask what kind of help promotes human growth in agency and competence—not helplessness or entitlement.

I have presented a case for slowing the impulse to outsource emotional health issues to MH professionals so that we can learn to access the growth potential of being ourselves in our real relationships.

As I conclude, however, I believe it is crucial to consider the limits of human nurture. A biblical view presents the most significant relationship rupture and source of human insecurity as flowing out of ignoring our creator God. The greatest act of nurture is seen in a reconciling God who, being rich in mercy and compassion, comes down to us in our struggles:

Come to me, all you who are weary and burdened, and I will give you rest. Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls. For my yoke is easy and my burden is light. (Matthew 11:28-30)

His mercy, embodied in Jesus, is conveyed in the invitation—not to try harder or fix ourselves, but to respond as the broken people we are.

 

Dr Jenny Brown is Director Emeritus of the Family Systems Institute (FSI) in Sydney, Australia, developer of the Parent Hope Project, and has over 35 years’ clinical experience in child, couple, and family health. She is the author of several books, including Growing Yourself Up (2012; 2017) and Confident Parenting (2020).

 

ENDNOTES

† This article is based on material presented in Dr Jenny Brown’s 2021 New College Lecture Series, Nurture: Confronting a Crisis, especially Lectures 1 & 3. The lectures, including question time, can be viewed at https://newcollege.unsw.edu.au/academic-program/new-college-lectures

[1] S. Nochaiwong, C. Ruengorn, K. Thavorn, et al., ‘Global prevalence of mental health issues among the general population during the coronavirus disease-2019 pandemic: a systematic review and meta-analysis’. Sci Rep 11, 2021, p10173. https://doi.org/10.1038/s41598-021-89700-8 (all URLs accessed November 2021).

[2] ABS National Survey of Mental Health and Wellbeing: Summary of Results 2008. www.abs.gov.au/statistics/health/mental-health/national-survey-mental-health-and-wellbeing-summary-results/latest-release

[3] Australian Institute for Health & Welfare www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/medicare-subsidised-mental- health-specific-services

[4] A. Losada-Baltar, J. Á. Martínez-Huertas, et al., ‘Longitudinal correlates of loneliness and psychological distress during the lockdown situation due to COVID-19. Effects of age and self-perceptions of aging’. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, Jan 13, 2021. https://doi.org/10.1093/geronb/gbab012

[5] R. Jia, K. Ayling, et al., ‘Mental health in the UK during the COVID-19 pandemic: cross-sectional analyses from a community cohort study’. BMJ open, Vol.10(9). https://bmjopen.bmj.com/content/10/9/e040620

[6] Australian Institute of Family Studies, ‘Growing up In Australia Report’ Sept 30, 2021. https://growingupinaustralia.gov.au/research-findings/snapshots/self-injury-among-adolescents

[7] David P. Kraft, ‘One Hundred Years of College Mental Health’. Journal of American College Health Vol.59(6), 2011, pp477-481.

[8] Mental Health Services in Australia (Australian Institute of Health and Welfare Report), last updated 14 Oct. 21) https://www.aihw.gov.au/reports/mental-health-services/mental- health-services-in-australia/report-contents/expenditure-on-mental-health-related-services

[9] An example of this trend can be seen in a recent call for loneliness to be recognised as an issue to be addressed by the medical community. In response to this call, McLennan & Ulijaszek warned: ‘The medicalisation of social issues has not worked in the past. From obesity to HIV/AIDS, health researchers and practitioners are fighting—with limited success—to convince society that public health problems require integrated and holistic approaches. Medicalisation of loneliness will discourage the collaboration needed, and medicine probably has no effective instruments with which to single-handedly address the absence of human connection.’ (‘Beware the medicalisation of loneliness’, The Lancet Vol. 391, April 14, 2018, p1480.)

[10] R. Elmore, L. Schmidt, et al., ‘Risk and Protective Factors in the COVID-19 Pandemic: A Rapid Evidence Map’. Frontiers in Public Health Vol. 8, 2020. https://doi.org/10.3389/fpubh.2020.582205

[11] Lynn Williams, ‘Fitter, better rested, more appreciative: research reveals the positive changes experienced by some during lockdown’. The Conversation, Jan 21, 2021. https://theconversation.com/fitter-better-rested-more-appreciative-research-reveals-the-positive-changes-experienced-by-some-during-lockdown-152907

[12] E. A. Holmes, A. Ghaderi, et al., ‘The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science’. The Lancet Psychiatry Vol. 5(3), March 2018, pp237-286.

[13] P. Cuijpers, A. Stringaris, & M. Wolpert, ‘Treatment outcomes for depression: Challenges and opportunities’. The Lancet Psychiatry Vol.7(11), Nov 1, 2020, pp925-927.

[14] D. Adam, ‘Mental health: On the spectrum’. Nature Vol. 496, 2013, pp416–418.

[15] Research Domain Criteria Initiative, National Institute of Mental Health www.nimh.nih.gov/research/research-funded-by-nimh/rdoc

[16] S. E. Taylor, ‘Tend and Befriend: Biobehavioral Bases of Affiliation Under Stress’. Current Directions in Psychological Science Vol.15(6), 2006, pp273-277.

[17] K. Smith, Everything Isn’t Terrible: Conquer Your Insecurities, Interrupt Your Anxiety, and Finally Calm Down (Hachette Books, 2019).

[18] J. Brown, Growing Yourself Up: How to bring your best to all of life’s relationships. 2^nd Edn. (Exisle Publishing, 2017), p75.

[19] J. Brown, Op. cit.

[20] On a rough comparison, 17% sought professional help for MH issues in a 12 month period (NCLS), similar to the 20% of the general population mentioned earlier.

[21] Esmari Faull, ‘Christian Religion and Wellbeing’. Scriptura Vol. 111, 2012, pp509-519

[22] National Church Life Surveys www.ncls.org.au/research/national-surveys

[23] M.E.Kerr, ‘Why do siblings often turn out very differently?’ A. Fogel, B. J. King & S. Shanker (eds.) Human Development in the Twenty-First Century (CUP, 2008), pp206-215.

[24] Tim Keller, The Reason for God (Hodder & Stoughton, 2009), p55.

[25] S. Sterland, R. Powell, 2011 NCLS Leader Survey (NCLS Research, 2014). ‘Thriving, Surviving and Burnout in Church Leaders, Factsheet’. www.ncls.org.au/sitemap/7182

[26] Tara Stenhouse,‘ Applying Bowen Theory to Pastoral Care’. J. Brown & L. Errington (eds.) Bowen Family Systems theory in Christian ministry (Family Systems Practice, 2019), p123. See also Anna Moss ‘Can Bowen Theory help us avoid burnout?’ in chapter 9 of the same volume.

[27] T. Stenhouse, Op. cit., p128.

[28] J.Brown, Op.cit., 2017, p266.

[29] Lauren Errington, ‘Quarrelsome or Caught in a Quandary?’.  J. Brown & L. Errington (eds.) Bowen Family Systems theory in Christian ministry (Family Systems Practice, 2019), p143.

[30] T. Keller, Hope in Times of Fear: The Resurrection and the Meaning of Easter (John Murray Press, 2021) p118.

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