Inside Anorexia: Understanding the Mental & Physical Impacts

Anorexia’s Grip on the Mind & Body 

Anorexia nervosa, more commonly known as anorexia, is an eating disorder marked by significantly low body weight, an extreme fear of weight gain, and a distorted perception of one’s body weight.[1] There are two main subtypes of anorexia: the first includes a restricted diet with extensive weight loss and lack of energy intake, while the second includes binge-purge eating behaviors where the person will combine episodes of excessive eating and self-induced vomiting. Nevertheless, both subtypes are driven by the individual’s motivation to control their weight and shape.[2,3]  

Due to the drastically decreased intake of nutrients of those with anorexia people suffering from the eating disorder can experience a wide range of physical, emotional, and behavioral symptoms including:[4]

• An unrealistic perception of body image or weight

• Fear of becoming fat 

• Thin appearance 

• Frequently skipping meals 

• Irritability 

• Social withdrawal 

• Abnormal blood count 

• Dry and/or yellowing skin 

• Fatigue 

• Eroding teeth from vomiting 

• Excessive exercise 

• Frequently checking mirrors or reflections for perceived flaws  

In recent years, research on the biological causes of anorexia has sharply increased. Researchers have begun focusing on possible genetic factors that may explain why certain individuals are at higher risk for developing anorexia than others. Additionally, certain personality characteristics have been linked to the development of anorexia including those that exhibit obsessive-compulsive tendencies, or those suffering from additional mental illnesses, such as anxiety or depression.[5,6] While males also suffer from anorexia, young girls are increasingly at risk of becoming anorexic due to the emphasis on thinness being equated to beauty, especially within Western culture.[7]

Physiological Effects 

Anorexia can have considerable effects on the human body, and may even become fatal. The major concern for those struggling with this eating disorder is the effects it has on the cardiovascular system, as heart damage is the most common reason for hospitalization in those with anorexia.[8] Moreover, for those suffering from the subtype of anorexia that includes purging, there is a greater risk of depleting the body of electrolytes which are essential in muscle contractions, notably the heartbeat.[9,10] With the restricted consumption of calories, the body is forced to break down its own tissue as fuel, with muscles being some of the first organs to go once fat has already been utilized. The heart also receives less energy leading to a drop in pulse and blood pressure from the lack of expendable energy. Hence there is a major risk for heart failure and mitral valve prolapse, a heart disease that affects the efficacy of the valve between the left heart chambers.[11] 

Another system that comes under concern is the gastrointestinal (GI) tract, especially concerning purging (i.e., forced vomiting or bowel movements). When an individual purges, it can interfere with the normal functioning of the stomach; the constant vomiting can lead to stomach pain and bloating, block the intestines from masses of undigested foods, and lead to nausea, thus perpetuating the feeling of needing to vomit.[12] Additionally, the stomach and esophagus can become worn down by the acid within the stomach, and in some cases rupture. The additional use of laxatives can also cause the individual to be constipated as the long-term restriction of food causes their body to no longer be able to digest food properly. It can also cause the body to become dependent on laxatives to have normal bowel movements.[13]

Many women will lose their menstrual cycle during severe cases of anorexia; this loss is due to the decrease in thyroid hormones that can both stop a woman’s cycle but also lead to bone loss, and a reduction in resting metabolic rate.[14,15] Furthermore, the effects of starvation can lead to high cholesterol levels and a drop in body temperature due to a lack of energy. Malnutrition can also decrease infection-fighting white blood cells making the individual more prone to sickness.[16] These combined factors have led eating disorders to be categorized as one of the deadliest disorders that currently exist.  

Neuropsychological Effects 

A major concern for those suffering from an eating disorder is the prevalence of suicide - roughly one-quarter to one-third of those with an eating disorder have attempted suicide, with 80% of those attempts occurring during depressive episodes.[17] In fact, depression and anxiety are two of the most common comorbid disorders related to anorexia. In a review by Calvo-River et al. (2022) the prevalence rate for depression and anorexia has been reported between 30 and 80%; such a large rate has been proposed due to the lack of studies investigating the relationship between the two pathologies.[18] Anxiety has also been found to have a large prevalence rate as Swinbourne et al. (2012) reported that from the 100 women presenting symptoms of disordered eating, 69% of them reported the onset of anxiety which proceeded to the onset of the eating disorder. From that, the most common anxiety diagnosed was social phobia (42%) and post-traumatic stress disorder (26%).[19] 

In addition, significant effects of anorexia nervosa have also been detected in numerous cognitive and neurological abilities. Due to the decrease in calories consumed by the individual, a person becomes unable to concentrate and often becomes obsessed with food. Additionally, the lack of nutrient intake damages the layer of lipids that are responsible for insulating neurons and allowing for more effective and rapid electrical conduction, thus slowing down signals being sent between neural connections between the brain and the body.[20]

The decrease in neurological function has led to the investigation into the effects anorexia has on numerous neuropsychological variables including:[21-23] 

• Executive Functioning: attention, planning, cognitive flexibility, set shift, mental flexibility 

• Learning: new rule learning, visual learning, verbal learning 

• Memory: verbal memory and nonverbal memory, working memory  

• Verbal Functioning: verbal fluency, verbal inhibition, verbal reasoning 

• Visuospatial Ability: spatial planning, visuospatial representation

• Speed of information processing

Executive functioning has been one of the most well-researched cognitive functions studied concerning anorexia as the effects of starvation have been shown to impair attention, mental flexibility, cognitive function, and decision-making.[24,25] In fact, papers such as Stedal et al (2021), Zakzanis et al. (2010), Grau et al. (2019), and Weider et al. (2014) all highlighted or found significant effects in individual executive functioning. Most notable were those found in Stedal et al. (2021) which discussed the possibility that the duration of illness may be linked to how severe the deficits in neuropsychological functioning are. Young individuals with a shorter duration of illness showed little difference in their performance compared to the typical control group.[26] However, this is in contrast to what has been previously found within adult groups. There is typically an overall low performance in all domains tested, including executive functioning, compared to the control group. Thus, the evidence seems to show that the duration of the eating disorder may be directly related to the negative effects on the brain.[27] Nevertheless, this idea is not the dominant one, as it was found in only four studies analyzed by Stedal et al. (2021) and so more investigation needs to be made into the relationship between the two variables.[28] 

Additionally, the lack of cognitive flexibility in individuals who suffer from anorexia poses a challenge once placed in therapy. Stedal et al. (2021) notes that patients' lack of willingness to change their thinking patterns, paired with increased compulsive behaviors for those who may purge, create reluctance to modify their thinking and eating patterns.[29] Thus, cognitive inflexibility and set cognitive shift can make key parts of therapy such as goal setting, collaboration, and thought experiences a challenge.

Memory has also been shown to be greatly impacted by anorexia nervosa. Zankzanis et al (2010), analyzed 36 different studies comparing the cognitive impairments between those suffering from anorexia nervosa and bulimia nervosa, a type of eating disorder characterized by episodes of binge eating followed by purging. From the 36 studies, a large effect size was found for deficits in decision-making, verbal memory, immediate and long-delay visual memory, and psychomotor speed.[30] The memory deficits were consistent with those highlighted by Aspen, et al. (2014) as eating disorder patients seemed to have a bias for memory of words that related to the body and body shape.[31] 

Misperceptions of body image in the mind constitute another pivotal focus in research on the effects of anorexia. Distortion of body image has been attributed to difficulties in visual perception and may even be linked to alterations in visual memory.[32] As Grau et al. (2019) propose individuals with eating disorders may process and organize information in less time and less efficiently.[33] Additionally, impairments in spatial perception and representation may affect the individual’s idea of what their body truly looks like. Typically, those with anorexia will rate their ideal body figure and figures they think others find more attractive as thinner than their current figure, and also thinner than what they believe they currently look like.[34]

Treatment 

There are multiple forms of treating anorexia nervosa, however, the most widely used for the treatment of eating disorders is Cognitive Behavioral Therapy (CBT). Mainly used with adults suffering from anorexia, the main goal of CBT is to specifically focus on returning the client to regular eating habits and challenging ideals that continue the overvaluation of their shape and weight.[35] CBT pushes the client to challenge their unrealistic thoughts about their appearance, encourages them to stop excessively exercising, and brings them into a space that can reinforce healthier eating habits. 

Conversely, the use of family-based treatment has shown exceptional improvements in adolescents suffering from anorexia, with Lock et al. (2010) citing a full or partial remission rate of 89% for individuals who used this form of therapy to recover from their eating disorder.[36] The gold standard for treating young adults with anorexia,[37] family-based therapy can be conducted with the individual's entire family or just their parents/guardians. Families must be involved in the recovery process of minors due to the fact their support can form as a short-term catalyst to help the recovery process. Additionally, bringing in the family can bring about the implementation of family meal patterns, allowing them and the clinician to suggest and try out methods to return the child’s eating patterns to normal.[38] Muratore & Attia (2021) note that more recently, developments have been made to hold sessions with parents only, as studies have indicated holding parent-focused treatment brings out better remission rates in adolescents.[39]

In addition to predominant methods, acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT) are two new forms of treatment for anorexia on the rise. Both of these treatments emphasize the importance of mindfulness and acceptance during recovery as a way to reduce maladaptive behaviors. A recent pilot study conducted using acceptance and commitment therapy shows improvements in both weight and eating disorder symptoms, which may reduce rehospitalizations after individuals are discharged.[40] 

In more severe cases, individuals may need to attend multiple-day treatment programs typically held in hospitals allowing them access to medical care, individual or group therapy, and nutritional education. Some individuals may choose residential treatment. This treatment option allows individuals to temporarily live in the facilities which can assist those who have been to the hospital many times or show no signs of improvement through conventional avenues or rehabilitation.[41] 

Future Steps

A main issue with investigating the effects of anorexia, and other eating disorders, on individuals is the high rates of comorbid disorders.[42] Grau et al. (2019) reported that in their group of long-duration eating disorder patients, approximately 54-58% presented comorbidities, such as anxiety, depression, personality disorders, or substance use disorders.[43] Thus, more investigation must be made into how these comorbid effects may contribute to or worsen both physiological and neuropsychological effects on individuals with eating disorders. 

Another issue is that many studies have only investigated the effects on adult populations and neglect those of adolescents. Additionally, tests typically used to measure test performance are developed using an adult population, making it more difficult to get an accurate representation when using them on adolescents.[44] Thus, given the high rate of anorexia within youth populations, more accurate research must be done into the effects of eating disorders on adolescent populations and whether those changes in the brain and body can be reversed with time. 

Furthermore, more strides must be taken to diversify the population pool as many studies on this topic have been produced by overlapping authors and/or laboratories.[45] Nevertheless, these findings pose a great insight into the long-lasting changes to the human brain and body for those suffering from anorexia nervosa. 

If you or someone you know is struggling with extreme body shame and/or a difficult relationship with food, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist, or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 Stedal, K., Scherer, R., Touyz, S., Hay, P., & Broomfield, C. (2021). Research Review: Neuropsychological functioning in young anorexia nervosa: A meta‐analysis. Journal of Child Psychology and Psychiatry, 63(6), 616–625. https://doi.org/10.1111/jcpp.13562 

2 Anorexia nervosa - Symptoms and causes - Mayo Clinic. (2018, February 20). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591 

3 National Eating Disorders Association. (2018, February 22). Health consequences. https://www.nationaleatingdisorders.org/health-consequences

4 “Anorexia Nervosa” Mayo Clinic

5 Ibid. 

6 Zakzanis, K. K., Campbell, Z., & Polsinelli, A. J. (2010). Quantitative evidence for distinct cognitive impairment in anorexia nervosa and bulimia nervosa. Journal of Neuropsychology, 4(1), 89–106. https://doi.org/10.1348/174866409x459674

7 “Anorexia Nervosa” Mayo Clinic

8 Northwestern Medicine. (2016). Disordered eating and your heart. Northwestern Medicine. https://www.nm.org/healthbeat/healthy-tips/anorexia-and-your-heart 

9 National Eating Disorders Association. (2018)

10 Northwestern Medicine. (2016)

11 “Anorexia Nervosa” Mayo Clinic

12 National Eating Disorders Association (2018)

13 Ibid. 

14 “Anorexia Nervosa” Mayo Clinic

15 National Eating Disorders Association (2018)

16 Ibid. 

17 Smith, A. R., Zuromski, K. L., & Dodd, D. R. (2018). Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Current Opinion in Psychology, 22, 63–67. https://doi.org/10.1016/j.copsyc.2017.08.023

18 Calvo-Rivera, M. P., Navarrete-Páez, M. I., Bodoano, I., & Gutiérrez-Rojas, L. (2022). Comorbidity between anorexia nervosa and Depressive Disorder: A Narrative review. Psychiatry Investigation, 19(3), 155–163. https://doi.org/10.30773/pi.2021.0188

19 Swinbourne, J., Hunt, C., Abbott, M. J., Russell, J., St Clare, T., & Touyz, S. (2012). The comorbidity between eating disorders and anxiety disorders: Prevalence in an eating disorder sample and anxiety disorder sample. Australian and New Zealand Journal of Psychiatry, 46(2), 118–131. https://doi.org/10.1177/0004867411432071

20 National Eating Disorders Association (2018)

21 Weider, S., Indredavik, M. S., Lydersen, S., & Hestad, K. (2014). Neuropsychological function in patients with anorexia nervosa or bulimia nervosa. International Journal of Eating Disorders, 48(4), 397–405. https://doi.org/10.1002/eat.22283

22 Grau, A., Magallón-Neri, E., Faus, G., & Feixas, G. (2019). Cognitive impairment in eating disorder patients of short and long-term duration: a case-control study. Neuropsychiatric disease and treatment, 15, 1329–1341. https://doi.org/10.2147/NDT.S199927 

23 Ibid.

24 Weider, et al., (2014)

25 Grau et al., (2019)

26 Stedal et al., (2021) 

27 Ibid. 

28 Ibid. 

29 Ibid. 

30 Zakzanis et al., (2010)

31 Aspen, V., Darcy, A., & Lock, J. (2013). A review of attention biases in women with eating disorders. Cognition & Emotion, 27(5), 820–838. https://doi.org/10.1080/02699931.2012.749777

32 Grau et al., (2019)

33 Ibid. 

34 Zakzanis et al., (2010)

35 Muratore, A. F., & Attia, E. (2021). Current therapeutic approaches to anorexia nervosa: state of the art. Clinical Therapeutics, 43(1), 85–94. https://doi.org/10.1016/j.clinthera.2020.11.006 

36 Lock, J., Grange, D. L., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing Family-Based Treatment with Adolescent-Focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025. https://doi.org/10.1001/archgenpsychiatry.2010.128 

37 Muratore & Attia (2021)

38 Ibid. 

39 Ibid. 

40 Ibid. 

41 Eating disorder treatment: Know your options. (2017, July 14). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/eating-disorders/in-depth/eating-disorder-treatment/art-20046234

42 Weider et al., (2014)

43 Grau et al., (2019) 

44 Stedal et al., (2021) 

45 Ibid. 

The Impact of Unfulfilled Dreams

The Unrecognized Grief

Grief is an often overwhelming emotion commonly associated with losing a loved one or a personal tragedy. But, what if grief arises from a dream that never materializes or when life continually falls short of expectations? Nonfinite grief occurs when one mourns for what was never realized as opposed to grieving something that has been lost.[1] In terms of duration, nonfinite grief is a continuing presence of loss that may be physical, psychological, and/or emotional.[2] In a world where life's disappointments and unfulfilled hopes can be devastating, understanding nonfinite grief can help people process and comprehend the spectrum of human emotional experiences.[3]

Assumptive World

Throughout a person's lifetime, their early experiences shape their beliefs, expectations, and assumptions about how the world operates. These foundations are influenced by various factors such as culture, people's behaviors, upbringing, and other elements, collectively called the "assumptive world".[4] Conversely, the shattered assumptions theory, introduced by Janoff-Bulman in the context of traumatic experiences, explains that individuals rely on these assumptions about the world and themselves to maintain healthy human functioning.[5] Edmondson et al. (2011) explains that without these assumptions, individuals may face a breakdown of their life narrative and a loss of self-identity, as described in the shattered assumptions theory.[6] The predictable worldview's function is to provide individuals with a sense of purpose, self-worth, and the illusion of invulnerability.[7] 

Conversely, when one’s assumptive world undergoes severe disruptions, individuals can experience nonfinite grief. This grief can manifest from different types of life experiences, as demonstrated by the following examples:

Physical: An athlete has been diligently preparing for a life-changing game. Due to a recent injury, they were rendered ineligible to participate in that pivotal game and left devastated.

Psychological: An individual tirelessly worked towards a promotion at their job. They were passed over, leaving them with a deep sense of disappointment.

Emotional: An individual longs for the day they exchange vows with their long term partner. However, as the years pass, they find themselves single and the dream of marriage seemingly slipping away.

Recognizing the Grief

Grief, when it falls outside of societal norms, can be hard to identify. The Dual Process Model for Non-Death Loss and Grief displays some of the everyday experiences of an individual oscillating between loss orientation and restoration orientation.[8] Wang et al. (2021) explains how loss orientation refers to the focus on coping with the loss itself whereas restoration orientation is a coping strategy that focuses on emotional recovery.[9]

In the Dual Process Model (as shown below) people oscillate between two types of orientation during their every day lives.[10]

In order to try to recognize one’s grief, the following three main factors separate nonfinite grief experiences from grief caused by death:[11]

1. The loss causes a persistent feeling of despair and emptiness from the reality shaped by their previous expectations with their envisioned future.

2. The loss is due to an inability to meet developmental expectations.

3. The loss is intangible, such as a loss of one’s hopes or ideals related to what the individual believes should have, could have, or would have been.

Furthermore, individuals grappling with nonfinite loss, such as erosion of long-cherished hopes and aspirations, often contend with persistent uncertainty regarding what the future holds.[12] A pervasive feeling of helplessness and powerlessness accompanies this ongoing loss, which is often met with little recognition or acknowledgment by others.[13]

Finding new meaning to life

Discovering new meaning to life can feel incredibly challenging especially when initial hopes and expectations were high. Amidst the grieving process, acceptance is more about recognizing that the new reality is permanent rather than merely adjusting.[14] Furthermore, acceptance includes taking a non-judgemental attitude towards oneself rather than labeling the grieving as a negative or positive experience.[15] When grappling with the complexities of grief, specialized therapy such as Complicated Grief Therapy (CGT) can help. This therapy is designed to address intense yearning, persistent longing, intrusive thoughts, and the acceptance of the reality of loss.[16] In addition to alleviating these specific symptoms, CGT also emphasizes the importance of personal growth, nurturing relationships as part of the healing process, and is based on attachment theory.[17] CGT with elements of cognitive-behavioral principles has been shown the most promise for individuals.[18]

An individual in CGT would cover seven core themes spanning over 16 sessions, including:[19]

1. Understanding and accepting grief

2. Managing painful emotions

3. Planning for a meaningful future

4. Strengthening ongoing relationships

5. Telling the story of the loss

6. Learning to live with reminders

7. Establishing an enduring connection with memories of the loss

Although 16 sessions is recommended, CGT is a flexible program. 

Another valuable approach for addressing grief is Acceptance and Commitment therapy (ACT).[20] Similarly to CGT, ACT uses core themes for individuals to work through their loss and life transitions including:[21]

1. Acceptance or willing to experience negative emotions or thoughts

2. Cognitive defusion

3. Contact with the present moment 

4. Self as context

5. Values

6. Committed Action
   

Malmir et al. (2017) explored the effectiveness of ACT for grieving individuals between the ages of 20 and 40 who were experiencing a range of symptoms, including anxiety, shortness of breath, illusion, and sleep disturbances.[22] The before and after outcomes were evaluated using a questionnaire designed to gauge the participant’s level of hope and anxiety.[23] The results of ACT therapy showed a significant reduction in symptoms among the eleven women and six men who received therapy compared to the ten women and seven men who did not.[24] The effectiveness of this modality in terms of healing from grief comes from increased cognitive flexibility, which is the main component of ACT.

If you or someone you know are experiencing nonfinite grief and loss that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Kelly Valentin

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Bruce, E. J., & Schultz, C. L. (2001). Nonfinite Loss and Grief: a psychoeducational approach. https://openlibrary.org/books/OL8601025M/Nonfinite_Loss_and_Grief

2 Neimeyer, R. A., Harris, D. L., Winokuer, H. R., & Thornton, G. (2021). Grief and bereavement in contemporary society: Bridging Research and Practice. Routledge.

3 Harris, D. L. (2011). Counting our losses: Reflecting on Change, Loss, and Transition in Everyday Life. Routledge.

4 Parkes, C. M. (1971). Psycho-social transitions: A field for study. Social Science & Medicine. https://doi.org/10.1016/0037-7856(71)90091-6

5 Edmondson, D., Chaudoir, S. R., Mills, M. A., Park, C. L., Holub, J., & Bartkowiak, J. (2011). From shattered assumptions to weakened worldviews: trauma symptoms signal anxiety buffer disruption. Journal of Loss & Trauma. https://doi.org/10.1080/15325024.2011.572030

6 Ibid.

7 Ibid.

8 Harris (2011)

9 Wang, W., Song, S., Chen, X., & Yuan, W. L. (2021). When learning goal orientation leads to learning from failure: the roles of negative emotion coping orientation and positive grieving. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2021.608256

10 Stroebe, W., Schut, H., & Stroebe, M. S. (2005). Grief work, disclosure and counseling: Do they help the bereaved?. https://doi.org/10.1016/j.cpr.2005.01.004

11 Harris (2011)

12 Bruce, E. J., & Schultz, C. L. (2001). Nonfinite Loss and Grief: a psychoeducational approach. https://openlibrary.org/books/OL8601025M/Nonfinite_Loss_and_Grief

13 Ibid.

14 Cianfrini, L. R., Richardson, E. J., & Doleys, D. (2021). Pain psychology for clinicians: A Practical Guide for the Non-Psychologist Managing Patients with Chronic Pain. Oxford University Press.

15 Ibid.

16 Wetherell, J. L. (2012). Complicated grief therapy as a new treatment approach. Dialogues in Clinical Neuroscience. https://doi.org/10.31887/dcns.2012.14.2/jwetherell

17 Ibid.

18 Ibid.

19 Iglewicz, A., Shear, M. K., Reynolds, C. F., Simon, N. M., Lebowitz, B. D., & Zisook, S. (2019). Complicated grief therapy for clinicians: An evidence‐based protocol for mental health practice. https://doi.org/10.1002/da.22965

20 Speedlin, S., Milligan, K., Haberstroh, S., & Duffey, T. (2016). Using acceptance and commitment therapy to negotiate losses and life transitions. Research Gate.

21 Bohlmeijer, E. T., Fledderus, M., Rokx, T., & Pieterse, M. E. (2011). Efficacy of an early intervention based on acceptance and commitment therapy for adults with depressive symptomatology: Evaluation in a randomized controlled trial. https://doi.org/10.1016/j.brat.2010.10.003

22 Malmir, T., Jafari, H., Ramezanalzadeh, Z., & Heydari, J. (2017). Determining the effectiveness of acceptance and commitment therapy (ACT) on life expectancy and anxiety among bereaved patients. https://doi.org/10.5455/msm.2017.29.242-246

23 Ibid.

24 Ibid. 

The Role of Gratitude in Improving Mental Health

Focusing on the Good 

Gratitude has its foundational roots in the humanities, from ancient philosophical studies, to religious conceptualizations, and evolutionary theories. Though gratitude has traditionally been understood and studied in this way, novel insights, questions, and understandings are being developed under the lens of contemporary scientific research today. In the past few decades gratitude has been studied in increasingly precise contexts, from early childhood education, to prosocial behavior in the workplace and potential for chronic disease treatment. Nevertheless, gratitude is still quite difficult to define. Is it an emotion, a virtue or a behavior? The APA gives a general description of gratitude as part of a wider outlook on life that involves noticing and appreciating the positive aspects of life.[1] Though there are many conceptualizations of gratitude, Emmons & McCullough (2003) defined gratitude in two parts: 1) recognizing that one has obtained a positive outcome and 2) recognizing that there is an external source for this positive outcome.[2]

In general, gratitude has been shown to present a plethora of benefits for one’s mental and physical health. It may foster a more positive mood, induce better sleep, and even lower disease markers and inflammation in the body.[3] Additionally, depressive symptoms, substance abuse, anxiety, chronic pain, and risk of disease may be lowered with the implementation of daily gratitude practices.[4] Cultivating feelings of gratitude through practices of mindfulness and daily journaling can fortify relationships with others as well as increase empathy and prosocial behavior. Overall, expressions and practices of gratitude have been extensively studied for its ability to increase well-being, longevity, and happiness. 

The origins of gratitude 

Though gratitude has often been thought of as merely an intuitive emotion or feeling, there have been key developments in various fields that have led to our increased understanding of gratitude and the ways it can be qualitatively and quantitatively measured. 

Evolutionary: 

The questions surrounding gratitude and its origins can be traced back centuries to evolutionist Darwin. In The Descent of Man (1871), he offers the possibility that humans and other animals share collective emotions, “even the more complex ones such as jealousy, suspicion, emulation, gratitude, and magnanimity.”[5] With this, gratitude may have played a unique role in human social evolution. It has been posited that gratitude is an adaptation for what Robert Trivers first coined as “Reciprocal Altruism” in 1971, or the sequential exchange of costly benefits between non relatives.[6] This is supported by a series of studies by prominent gratitude researchers Mccullough et al. (2008) which explain that a positive feeling of gratitude can alert us to the benefits we’ve received from others and inspire us to show appreciation, which will in turn make others more likely to help us again in the future.[7] The evolutionary advantage is that we become more interconnected and collectively stronger as a society, as strangers become friends and new allyships are created. 

Neurobiological: 

There have also been more recent studies which incorporate systematic ways of studying and measuring the biological origins of gratitude. In one key fMRI based study by Fox et al. (2015), higher ratings of gratitude correlated with increased brain activity in participants’ anterior cingulate cortex and medial prefrontal cortex. Activity in these regions has been linked to moral cognitive processes, social reward and interpersonal bonding, as well as emotion perception and theory of mind. Previously, it was unknown how the brain generated the range of feelings associated with gratitude; however, this study provides a window into gratitudes origins, as well as its relationship to mental health and resilience.[8]   

Factors that contribute to gratitude

Multiple studies have honed in on certain individual factors that may contribute to increased or decreased expressions of gratitude including personality, cognitive factors, and gender. 

1. Personality Traits: Recently, Szcześniak et al. (2020) studied the interaction among personality traits, emotional intelligence, and a grateful disposition. They found that both gratitude and emotional intelligence correlated positively and significantly with extraversion, openness to experience, agreeableness, and conscientiousness. Conversely, gratitude and emotional intelligence correlated negatively and significantly with neuroticism.[9]

2. Cognitive Factors: Certain cognitive factors may also influence the amount of gratitude one feels in a particular situation. Some examples include the perceived intention of the benefactor, the apparent cost to the benefactor, or the value of the gift which vary based on the situation.[10] This differs based on personal experience and background, perception of the situation, and even some larger cultural norms.   

3. Gender: In particular, Kashdan et al. (2009) hypothesized that women possess an advantage over men in experiencing and benefiting from gratitude. In this comparative study of reaction to gift appraisals, women viewed gratitude expression to be exciting and interesting while men were less likely to feel and express gratitude, made more critical evaluations of gratitude, and derived fewer benefits.[11]   

Along with the numerous individual factors which show variance in either lending to or inhibiting expressions of gratitude, there is also a wider discussion on gratitude as it relates to the complex interplay of religion, culture, and social norms. 

1. Religion: Gratitude has often been associated with and studied in conjunction with religion and spirituality. Specifically looking at the United States, a study by Krause (2009) found that more frequent church attendance and stronger God-mediated control beliefs are associated with positive changes in gratitude over time.[12] In accordance with these findings, a more generalized study of intergroup differences conducted by Ferenczi et al. (2021) examined religiousness, gratitude, and well-being over time and found that religiousness is linked to higher gratitude and moreover, an increase in gratitude can result in an increase in subjective well-being.[13] 

2. Culture: Cross cultural research often looks at the difference between individualist and collectivist cultures in the context of behavior, values, practices, and more. Srirangarajan et al. (2020) found evidence that across East Asian and Western cultures, being grateful generally seems to have a similar relationship with a wide variety of psychological variables including but not limited to life-satisfaction, stress and social anxiety, and anger.[14] Another more recent study carried out by Freitas et al. (2022) sampled a participant pool with diverse cultural backgrounds ranging from countries such as China, Brazil, Russia, and Turkey to investigate gratitude as a moral virtue. The main findings indicated that despite the broad array of cultures represented, gratitude as a virtue develops during childhood and is influenced by one's cultural group.[15] 

3. Parenting Style: As gratitude has been shown to have developmental roots, parenting styles and gratitude in children has also been examined. Obeldobel & Kerns (2021) conducted a literature review that showed how children’s gratitude was higher when parents modeled gratitude, there was a more secure parent–child attachment, and parents employed more supportive, autonomy granting, and warm parenting styles. These findings align with attachment theory, social learning and emotion socialization theories, and the find-remind-and-bind theory.[16] 

Individual Benefits 

Researchers have been interested in gratitude particularly in regard to its potential for improving one’s mental and emotional health for decades. Many key mechanisms and rationales for significant findings have been identified and discussed throughout the existing literature. More recent studies, though, have also begun to incorporate physical health and well-being into experimental design. 

1. Improving Physical Health: UCLA Health notes that gratitude supports heart health through the improvement of depression symptoms, increased sleep, improved diet and more frequent exercise - which all reduce the risk of heart disease.[17] Additionally, several studies show that a grateful mindset positively affects biomarkers associated with the risk for heart disease. One recent study by Jans-Beken et al. (2021) sought to provide an updated overview of the literature on the connection of gratitude to human health, specifically focusing on experimental study findings. The researchers state that gratitude interventions appear to positively affect a number of cardiovascular and inflammatory parameters, (e.g., a decrease in diastolic blood pressure with daily gratitude journaling) as well as improving sleep quality.[18] In addition, not only has gratitude journaling been shown to lessen depressive symptoms related to chronic illness, but has been shown to lessen inflammatory chronic disease biomarkers such as HbA1c (which is involved in blood sugar control). This is especially important given that high levels of HbA1c have been associated with chronic kidney disease, a number of cancers, and diabetes.[19] 

2. Improving Well-being: In addition to the evidence of improvements to physical health, many more studies support the idea that a grateful disposition is associated with greater life satisfaction, optimism, subjective well-being, positive affect, and overall happiness.[20] Some mechanisms by which gratitude can positively intervene in one’s life to improve general well-being include counteracting materialism and protecting against burnout. Specifically looking at student culture, Tsang et al. (2014) found that undergraduate students reported less life satisfaction, which could be explained by their lowered levels of gratitude. The study concluded that gratitude played an important mediating role for the negative relationship between materialism and life satisfaction. Grateful people may be less materialistic because they feel more satisfied with their lives - and thus, don’t feel much of a need to acquire new things in order to feel more satisfied.[21] 

3. Treating Mental Illness: While there is clearly strong evidence for gratitude’s role in improving both mental and physical health, several more studies are concentrating on gratitude interventions for specific psychological challenges and the related mechanisms by which these may elicit significant positive changes. 

   Through various meta-analysis and literature review studies, it is now commonly accepted that gratitude can play a key role in improving depressive symptoms. One recent development, though, comes from a study carried out by Tomczyk et al. (2022), examining gratitude and acceptance of illness for women who were at risk for clinical depression. They identified that women with elevated depressive symptoms who were more grateful (compared to those who were less grateful) were more accepting of their condition, which was related to increased well-being and decreased feelings of depression and anxiety.[22] 

   Gratitude can help promote long-term recovery from substance misuse. In particular, the Narcotic Anonymous (NA) program has adopted gratitude as a key component of recovery and urges members to practice gratitude on a daily basis on their journey toward successful recovery.[23] 

   Several more studies have been conducted under the topic of gratitude’s effect on mitigating stress and anxiety disorders, PTSD, and suicidal ideation. For example, Vieselmeyer et al. (2017) looked at the role that gratitude and resilience played in post-traumatic stress. Particularly relevant to contemporary events and the dramatic increase in the prevalence of community trauma like school shootings, these researchers found that people with high trait gratitude four months following the 2014 Seattle Pacific University shooting showed a stronger relationship between post-traumatic stress and post-traumatic growth, implying that very grateful people are also more resilient and willing to adopt a growth mindset post-trauma.[24] Another study by Li et al. (2015) examined the relationship between suicide ideation and gratitude, finding that the odds of suicidal ideation and suicide attempts were lower among adolescents who scored higher on gratitude, and furthermore, these results were mediated by both prevalence of stressful life events and self-esteem.[25]

   Perhaps one of the most widely studied and supported topics related to mental health and gratitude, though, is its effect on stress and depression. A comprehensive study by Wood et al. 2008 examined the direction of the relationships between trait gratitude, perceived social support, stress, and depression during a life transition. The key findings from this study is that gratitude seems to directly foster social support, and to protect people from stress and depression, which has major implications for clinical interventions.[26] 

4. Child/Adolescent Health: The Anxiety and Depression Association of America outlines the mental health benefits of gratitude for kids and teens including improving mood, increasing social connection, reducing suicide risk, and improving sleep. Many of the existing studies on child/adolescent gratitude and mental health examine a specific type of intervention (e.g., gratitude journaling) and its longitudinal effects. For example, one study by Tara et al. (2016) sought out to promote positive psychology evidence-based interventions for use in schools. They found that students who completed the gratitude intervention demonstrated enhanced school belonging and gratitude relative to the control group. Thus, a link was established between gratitude, sense of belonging and well-being for school-aged children.[27] The generalizability of this result, however, may not be definitive. In one gratitude article featured in the Journal of Positive Psychology, Hussong et al. (2018) states that children and adolescents often display wider variance in ways of expressing gratitude. In other words, there are different aspects of gratitude moments (i.e., awareness, thoughts, feelings, and actions) and the way that these facets appear in children.[28]

Social Benefits

A major implication of gratitude is in its social benefits. Studies have looked at how gratitude improves relationships between individuals, enhances productivity in the workplace, boosts well-being among students, and stimulates more helping behavior within collective spaces. Especially relevant to the demanding and highly stressful work environment of healthcare since the Covid-19 pandemic, Kersten et al. (2021) was motivated to investigate the effect of gratitude in mitigating and alleviating the effects of burnout in the workplace. They carried out a study, surveying an international sample of employees, showing a clear negative relationship between work-specific gratitude and disengagement, mediated by Interpersonal Helping Behavior (IHB).[29] 

Similarly, other studies have been interested in the relationship between gratitude and prosocial behavior. Prosocial behavior refers to a range of positive behaviors including positive interactions (e.g., friendly play or peaceful conflict resolutions), altruism (e.g., sharing, offering help), and behaviors that reduce stereotypes.[30]

Zhang (2022) was able to identify a positive relationship between gratitude and adolescents’ prosocial behavior as well as further clarify the mechanism by which the effect operates. Two factors in particular were identified as important to cultivating greater prosocial behavior: the sense of meaning in life and self-esteem. Researchers rationalized that the sense of meaning in life generally refers to an awareness of life goals, tasks, and missions, and hence is intertwined with positive physical and mental health, improved mood, and life satisfaction to promote gratitude and prosocial behavior. Moreover, higher self-esteem is recognized as a key factor in adolescents being more attuned to the behavior of others to then form a positive cognition of themself and others.[31]

Gratitude interventions 

It’s clear that gratitude has been conceptualized in many different ways throughout history and utilized within various disciplines and subfields of psychological study. Because of its applicability, gratitude is extremely well-studied and universally accepted as an intervention which can aid mental health struggles and increase life-satisfaction. From maintaining and improving relationships, fostering a more secure sense of self and well-being, as well as being more attuned to others around us, gratitude is an economical, effective, and comprehensive intervention. What are some ways, then, to cultivate a gratitude practice? 

1. Noting the Positive: One relatively simple practice is “counting blessings” or gratitude journaling (e.g., writing down things one is grateful for either daily or weekly). Another gratitude practice under the same paradigm as journaling is,“mental subtraction.” This activity involves imagining what life would be like if a positive event had not occurred and has been shown to greatly improve mood.[32] 

2. Mindfulness: According to Ochsner Health, mindfulness is defined as paying attention, on purpose, in the present moment, non-judgmentally. To practice mindfulness is simply to invite yourself to where you already are and to experience and acknowledge that moment without judgment or expectation.[33] Mindfulness has been shown to bring emotional regulation, steady attention, and physical healing over the past few decades with the emergence of modern neuroscience and numerous evidence-based studies.[34] While gratitude is central to happiness, mindfulness can help us cultivate it as it enables us to be present with the feelings and sensations of goodness in our life. Like gratitude, mindfulness is a practice which can be practiced daily and refined over time. 

3. Acceptance and Commitment Therapy (ACT): This psychotherapeutic intervention integrates the principles of both acceptance and mindfulness in order to increase flexibility in thinking and outcomes. In addition, this therapy hones in on defusion, engagement with emotions, articulation of life values, self-compassion, mindful gratitude, and stepwise movement in accord with one’s life values.[35] An article from positivepsychology.com states “gratitude is about feeling the right way, about the right things, and at the right time. It is inseparably linked with self-discipline and motivation.” Commitment to action and mindful behavior are both tenets of ACT and will also contribute to a stronger, more consistent gratitude practice.[36] 

Though both mindfulness and ACT are well studied and relatively easy to implement in daily life, there are some factors and limitations that have hindered one’s willingness to adopt practices and express gratitude. These include narcissism, gratitude turning into indebtedness or obligation, and cultural differences and cultural contexts which all affect the way we may experience and perceive gratitude. Generally though, gratitude has been posited as social glue which fortifies relationships. At its most effective, gratitude interventions have been shown to elicit positive changes behaviorally, mentally, and physically. It provides a wealth of benefits to those who commit to this principle as a daily practice and lens through which to view life rather than a short term solution. 

If you or someone you know would like to learn more about how to incorporate gratitude in daily life, learn about mindfulness and ACT, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 American Psychological Association. (2015, April 9). A grateful heart is a healthier heart [Press release]. https://www.apa.org/news/press/releases/2015/04/grateful-heart 

2 Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389. https://doi.org/10.1037/0022-3514.84.2.377 

3 APA (2015) 

4 American Psychological Association. (2012, August 5). Growing up grateful gives teens multiple mental health benefits, new research shows [Press release]. https://www.apa.org/news/press/releases/2012/08/health-benefits 

5 Trivers, R. L. (1971). The Evolution of Reciprocal Altruism. The Quarterly Review of Biology, 46(1), 35–57. http://www.jstor.org/stable/2822435 

6 McCullough, M. E., Kimeldorf, M. B., & Cohen, A. D. (2008). An Adaptation for Altruism: The Social Causes, Social Effects, and Social Evolution of Gratitude. Current Directions in Psychological Science, 17(4), 281–285. https://doi.org/10.1111/j.1467-8721.2008.00590.x

7 Suchak, M. (2017, February 1). The Evolution of Gratitude [Review of The Evolution of Gratitude]. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/the_evolution_of_gratitude 

8 Fox, G. R., Kaplan, J., Damasio, H., & Damasio, A. (2015). Neural correlates of gratitude. Frontiers in psychology, 6, 1491. https://doi.org/10.3389/fpsyg.2015.01491 

9 Szcześniak, M., Rodzeń, W., Malinowska, A., & Kroplewski, Z. (2020). Big Five Personality Traits and Gratitude: The Role of Emotional Intelligence. Psychology Research and Behavior Management, Volume 13, 977–988. https://doi.org/10.2147/prbm.s268643 

10 Allen, S. (2018). The Science of Gratitude. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Gratitude-FINAL.pdf?_ga=2.82610261.2142947331.1637096170-1362583773.1634590861 

11 Kashdan, T. B., Mishra, A., Breen, W. E., & Froh, J. J. (2009). Gender Differences in Gratitude: Examining Appraisals, Narratives, the Willingness to Express Emotions, and Changes in Psychological Needs. Journal of Personality, 77(3), 691–730. https://doi.org/10.1111/j.1467-6494.2009.00562.x 

12 Krause, N. (2009). Religious Involvement, Gratitude, and Change in Depressive Symptoms Over Time. International Journal for the Psychology of Religion, 19(3), 155–172. https://doi.org/10.1080/10508610902880204 

13 Ferenczi, A., Tanyi, Z., Mirnics, Z., Kovács, D., Mészáros, V., Hübner, A., & Kövi, Z. (2021). Gratitude, Religiousness and Well-Being. Psychiatria Danubina, 33(Suppl 4), 827–832.https://pubmed.ncbi.nlm.nih.gov/35026809/ 

14 Srirangarajan, T., Oshio, A., Yamaguchi, A., & Akutsu, S. (2020). Cross-Cultural Nomological Network of Gratitude: Findings From Midlife in the United States (MIDUS) and Japan (MIDJA). Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.00571 

15 Freitas, L. B. L., Palhares, F., Cao, H., Liang, Y., Zhou, N., Mokrova, I. L., Lee, S., Payir, A., Kiang, L., Mendonça, S. E., Merçon-Vargas, E. A., O’Brien, L., & Tudge, J. R. H. (2022). How weird is the development of children’s gratitude in the United States? Cross-cultural comparisons. Developmental Psychology. https://doi.org/10.1037/dev0001383 

16 Obeldobel, C. A., & Kerns, K. A. (2021). A literature review of gratitude, parent–child relationships, and well-being in children. Developmental Review, 61, 100948. https://doi.org/10.1016/j.dr.2021.100948 

17 Health benefits of Gratitude. UCLA Health System. (n.d.). https://www.uclahealth.org/news/health-benefits-gratitude   

18 Jans-Beken, L., Jacobs, N., Janssens, M., Peeters, S., Reijnders, J., Lechner, L., & Lataster, J. (2019). Gratitude and health: An updated review. The Journal of Positive Psychology, 15(6), 1–40. https://doi.org/10.1080/17439760.2019.1651888 

19 Allen, S. (2018). The Science of Gratitude. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Gratitude-FINAL.pdf?_ga=2.82610261.2142947331.1637096170-1362583773.1634590861 

20 Ibid. 

21 Tsang, J.-A., Carpenter, T. P., Roberts, J. A., Frisch, M. B., & Carlisle, R. D. (2014). Why are materialists less happy? The role of gratitude and need satisfaction in the relationship between materialism and life satisfaction. Personality and Individual Differences, 64, 62–66. https://doi.org/10.1016/j.paid.2014.02.009 

22 Tomczyk, J., Nezlek, J. B., & Krejtz, I. (2022). Gratitude Can Help Women At-Risk for Depression Accept Their Depressive Symptoms, Which Leads to Improved Mental Health. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.878819 

23 Chen, G. (2016). Does gratitude promote recovery from substance misuse? Addiction Research & Theory, 25(2), 121–128. https://doi.org/10.1080/16066359.2016.1212337 

24 Vieselmeyer, J., Holguin, J., & Mezulis, A. (2017). The role of resilience and gratitude in posttraumatic stress and growth following a campus shooting. Psychological Trauma: Theory, Research, Practice, and Policy, 9(1), 62–69. https://doi.org/10.1037/tra0000149 

25 Li, D., Zhang, W., Li, X., Li, N., & Ye, B. (2012). Gratitude and suicidal ideation and suicide attempts among Chinese Adolescents: Direct, mediated, and moderated effects. Journal of Adolescence, 35(1), 55–66. https://doi.org/10.1016/j.adolescence.2011.06.005 

26 Wood, A. M., Maltby, J., Gillett, R., Linley, P. A., & Joseph, S. (2008). The role of gratitude in the development of social support, stress, and depression: Two longitudinal studies. Journal of Research in Personality, 42(4), 854–871. https://doi.org/10.1016/j.jrp.2007.11.003 

27 Diebel, T., Woodcock, C., Cooper, C., & Brignell, C. (2016). Establishing the effectiveness of a gratitude diary intervention on children’s sense of school belonging. Educational and Child Psychology, 33(2), 117–129. https://doi.org/10.53841/bpsecp.2016.33.2.117 

28 Hussong, A. M., Langley, H. A., Thomas, T. E., Coffman, J. L., Halberstadt, A. G., Costanzo, P. R., & Rothenberg, W. A. (2018). Measuring gratitude in children. The Journal of Positive Psychology, 14(5), 563–575. https://doi.org/10.1080/17439760.2018.1497692 

29 Kersten, A., van Woerkom, M., Kooij, D. T. A. M., & Bauwens, R. (2021). Paying Gratitude Forward at Work. Journal of Personnel Psychology. https://doi.org/10.1027/1866-5888/a000296

30 Wright, J. D. (2015). International Encyclopedia of the Social & Behavioral Sciences |ScienceDirect. Sciencedirect.com. https://www.sciencedirect.com/referencework/9780080970875/international-encyclopedia-of-the-social-and-behavioral-sciences 

31 Zhang, D. (2022). The relationship between gratitude and adolescents’ prosocial behavior: A moderated mediation model. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.1024312 

32 Allen (2018) 

33 How Mindfulness and Gratitude Can Improve Your Well-Being | Ochsner Health. Ochsner Health System. https://blog.ochsner.org/articles/giving-thanks-how-mindfulness-and-gratitude-can-improve-your-well-being 

34 Gregoire, C. (2014, March 19). Mind and Body: Jack Kornfield on Gratitude and Mindfulness [Review of Mind and Body: Jack Kornfield on Gratitude and Mindfulness]. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/jack_kornfield_on_gratitude_and_mindfulness 

35 Fradkin, C. (2017). Janina Scarlet: Superhero Therapy: A Hero’s Journey Through Acceptance and Commitment Therapy. Journal of Youth and Adolescence, 46(7), 1629–1632. https://doi.org/10.1007/s10964-017-0658-8 

36 The Neuroscience of Gratitude and How It Affects Anxiety & Grief. (2019, April 9). PositivePsychology.com. https://positivepsychology.com/neuroscience-of-gratitude/#brain-changes 

"I Don’t Remember Last Semester" - Examining the Normalcy of Blacking Out On College Campuses

A Truth of College Life

College life is often associated with memorable experiences and substance experimentation. However, an alarming phenomenon has taken root on college campuses: "blacking out." Miller et al. (2018) note that 49% of college students who drink experience alcohol-induced blackouts.[1] In a society where excessive alcohol consumption has become commonplace among college students, it is crucial to explore the associated underlying influences and mental health issues, in addition to spreading support to those affected.

Understanding Blacking Out

Blacking out refers to a state of temporary amnesia triggered by excessive alcohol consumption, in which memories from experiences of heavy alcohol consumption cannot be recovered. Binge drinking (i.e., excessive drinking in short periods of time) is as prevalent as alcohol-induced blackout experiences among college students.[2] This indicates the link between college cultures of normalized, excessive drinking and frequent blackout experiences. In her memoir, “Blackout: Remembering the Things I Drank to Forget,” University of Texas alumni Sarah Hepola shares that through her research and interactions with current college students, she discovered that blacking out is now considered more casual than it once was 40 years ago, when she was attending UT.[3] In many college cultures, blacking out is often perceived as an inevitable rite of passage, trivializing its potential dangers as it is employed through peer pressure or initiations, particularly in fraternities and sororities.[4]

The National Institute on Alcohol Abuse and Alcoholism (NIAA) notes that blackouts can be separated into two categories:[5]

1. Fragmentary Blackouts - Fragmented memories from events during alcohol consumption exist, but without the ability to connect them.

2. Complete Amnesia - Memories from events during alcohol consumption cannot be recovered.

It is crucial to differentiate between occasional alcohol-related memory lapses and chronic blackouts, which might indicate underlying alcohol use disorder (AUD). Identifying these distinctions early-on can significantly impact an individual's mental well-being and prevent future difficulties with alcohol addiction. It is also important to distinguish blacking out from passing out following alcohol consumption. While “passing out” is the loss of consciousness or falling asleep from excessive drinking, “blacking out” refers to the loss of memories and the inability to create new memories while in a state of excessive alcohol consumption.[6] While a person can blackout and subsequently pass out, it’s also possible to blackout while still remaining completely awake (but unaware).

Your Brain When You Blackout

The amount of alcohol that one's body can withstand depends on blood alcohol concentrations (BACs). The NIAA reports that BACs of about 0.16 percent (about twice the legal driving limit) and above can induce blackouts.[7] However, this value can vary and become lower among:[8]

• Those who consume anti-anxiety medications 

• Those who consume common anti-inflammatories (e.g., Advil/ibuprofen)

• Those who consume alcohol more frequently (indicative of a tolerance)

Many other substances like opioids and antidepressants, in combination with alcohol, can lessen the BAC threshold as well, increasing risks related to these drugs or medications (e.g., overdose or liver failure).[9]

This excessive amount of alcohol results in the temporary block of the transfer of memories, or memory consolidation, from short-term to long-term memory storage via brain structures including the hippocampus.[10,11] Specifically, blackouts lead to anterograde amnesia: the prevention of the formation or storage of new memories.[12] Banerjee (2014) notes that alcohol’s interaction with neurons in the brain leads to the enhancement of inhibitory neurotransmitters and pathways like GABA while lowering the function of excitatory neurotransmitters like glutamate.[13] Such processes lead to heavy intoxication symptoms of poor motor function, altered reward systems, slurred speech, impulsive behavior and poor memory.

From a long-term lens, Nunes et al. (2019) found that frequent blackouts and binge drinking can lead to degenerative and functional deficit trends in the brain through hippocampal and frontal brain damage.[14] Additionally, going to sleep intoxicated shortens the REM (Rapid Eye Movement) phase of sleep [15] which Peever & Fuller (2016) found is responsible for consolidating memories and information in the brain from that day.[16] Exacerbating the issue, this loss of REM sleep may contribute to both short-term and long-term memory/cognitive issues.[17]

Mental Health Consequences 

In addition to impacting cognitive functioning, blackouts inflict significant effects on one’s emotional well-being. Miller et al. (2020) found that in heavy-drinking college students, blackouts were related to increased symptoms of depression.[18] Further, students who experience blackouts may already struggle with anxiety and depression, and abuse alcohol as a coping tool. For example, alcohol can often be employed as a social anxiety “buffer”, as alcohol alleviates behavioral inhibitions.[19] In a survey of 772 college students by White et al. (2002), increased frequencies of blackouts were associated with lower grades, increased heavy drinking and increased frequencies of high-risk behaviors like vandalism.[20] College student blackouts can also impact many aspects of a young person's life including academics, physical health, depression and anxiety risk, memory and cognition, sexual assault risk, and even suicide.[21] 

Pertaining to the college cultures that promote the normalization of blackouts, Greek Life subpopulations are of particular interest. Turrisi et al. (2006) note that these organizations are linked to heavier alcohol consumption.[22] Further, Estaban et al. (2018) found that male fraternity engagement predicted high levels of binge drinking and other drug use in young adulthood as 45% of participants experienced alcohol use disorder (AUD) by age 35.[23] These rates were significantly higher when compared to non-fraternity-associated adults.[24] Additionally, as Cara Rosenbloom in The Washington Post (2019) remarks, eating disorder rates are increased for these college subgroups, and the term “drunkorexia” (purging before excessive alcohol consumption) has arisen on campuses.[25] This phenomenon has created tendencies of heavy and high-risk drinking to replace normal eating, particularly among women struggling with body image.[26] The lack of food in one’s system when consuming alcohol makes binge drinking even more dangerous, as it increases the rate of intoxication.

Shedding the Light on Blacking Out

Due to societal stigmas surrounding mental health, many students hesitate to seek help or support. Wombacher et al. (2019) add that most college students rationalize frequently blacking out while completely acknowledging that the habits are unhealthy.[27] It is crucial to normalize help-seeking behavior and offer accessible resources to those facing alcohol-related issues and potential mental health concerns. By promoting responsible drinking and educating students about the risks, universities can foster a safer environment conducive to positive mental health, both relevant to long and short-term life. Integrating mental health support into college curricula and readily available campus resources empowers students to address their concerns proactively.

Harm reduction approaches may target the engrained social norms on college campuses. In this way, resources may be provided to reduce high rates of negative consequences such as emergency room visits due to alcohol poisoning, anxiety and depression and dangerous behavior. Such educational approaches may spread information about:

• Substances to avoid combining with alcohol

• Ways to be mindful when partaking in alcohol consumption

• Safe sexual practices like consent

• Awareness to avoid situations of peer pressure

• Accessibility to counseling and medical care

• Bystander awareness training 

Additionally, student accessibility to forms of psychotherapy would lead to beneficial effects for students struggling with alcohol use. For example, Ehman & Gross (2019) found that Acceptance and Commitment Therapy (ACT), a modality used to focus on awareness of mental states and thoughts, in addition to Motivational Interviewing (MI), lead to reductions in alcohol consumption and less heavy drinking in college students.[28]

Blacking out might be perceived by many as an “ordinary part of college life”, but its implications on physical, mental and cognitive health require urgent attention. By raising awareness about the normalcy and consequences of blacking out, it is possible to dismantle the harmful aspects of social cultures that perpetuate this behavior. 

If one is experiencing excessive alcohol use, binge drinking, addiction, or blackouts that impair well-being and/or daily life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Miller, M. B., Merrill, J. E., DiBello, A. M., & Carey, K. B. (2018). Distinctions in Alcohol-Induced Memory Impairment: A Mixed Methods Study of En Bloc Versus Fragmentary Blackouts. Alcoholism, clinical and experimental research, 42(10), 2000–2010. https://doi.org/10.1111/acer.13850 

2 Juergens, J. (2023, April 17). Binge Drinking. AddictionCenter. https://www.addictioncenter.com/alcohol/binge-drinking/ 

3 Walsh, K. (2015, November 25). UT Unspoken: Students Reflect on Blackout Drinking Culture. The Daily Texan. https://thedailytexan.com/2015/11/25/ut-unspoken-students-reflect-on-blackout-drinking-culture/

4 Ibid. 

5 National Institute on Alcohol Abuse and Alcoholism. (2023 February). Alcohol’s Effects on Health: Research-Based Information on Drinking and its Impact. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/interrupted-memories-alcohol-induced-blackouts

6 Ibid.

7 Ibid. 

8 Ibid.

9 National Institute on Alcohol Abuse and Alcoholism. (2022, May 6). The Healthcare Professional’s Core Resource on Alcohol: Alcohol-Medication Interactions. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-medication-interactions-potentially-dangerous-mixes#:~:text=Nonsteroidal%20anti%2Dinflammatory%20drugs%20(NSAIDs,alcohol%20significantly%20increases%20the%20risk. 

10 Wetherill, R. R., & Fromme, K. (2016). Alcohol-Induced Blackouts: A Review of Recent Clinical Research with Practical Implications and Recommendations for Future Studies. Alcoholism, clinical and experimental research, 40(5), 922–935. https://doi.org/10.1111/acer.13051 

11 National Institute on Alcohol Abuse and Alcoholism

12 American Addiction Centers. (2023, July 12). Blackout Drunk: Signs, Causes, and Dangers of Blackout Drinking. https://americanaddictioncenters.org/alcoholism-treatment/blackout 

13 Banerjee N. (2014). Neurotransmitters in alcoholism: A review of neurobiological and genetic studies. Indian journal of human genetics, 20(1), 20–31. https://doi.org/10.4103/0971-6866.132750

14 Nunes, P. T., Kipp, B. T., Reitz, N. L., & Savage, L. M. (2019). Aging with alcohol-related brain damage: Critical brain circuits associated with cognitive dysfunction. International review of neurobiology, 148, 101–168. https://doi.org/10.1016/bs.irn.2019.09.002

15 Brower K. J. (2001). Alcohol's effects on sleep in alcoholics. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 25(2), 110–125.

16 Peever, J., & Fuller, P. M. (2016). Neuroscience: A Distributed Neural Network Controls REM Sleep. Current biology : CB, 26(1), R34–R35. https://doi.org/10.1016/j.cub.2015.11.011

17 Brower (2001)

18 Miller, M. B., DiBello, A. M., Merrill, J. E., Neighbors, C., & Carey, K. B. (2020). The role of alcohol-induced blackouts in symptoms of depression among young adults. Drug and alcohol dependence, 211, 108027. https://doi.org/10.1016/j.drugalcdep.2020.108027 

19 Locco, A. (2021, March 15). Alcohol and Blacking Out. Resurgence Behavioral Health. https://resurgencebehavioralhealth.com/blog/alcohol-blacking-out/ 

20 White, A. M., Jamieson-Drake, D. W., & Swartzwelder, H. S. (2002). Prevalence and correlates of alcohol-induced blackouts among college students: results of an e-mail survey. Journal of American college health : J of ACH, 51(3), 117–131. https://doi.org/10.1080/07448480209596339 

21 Juergens (2023)

22 Turrisi, R., Mallett, K. A., Mastroleo, N. R., & Larimer, M. E. (2006). Heavy Drinking in College Students: Who Is at Risk and What Is Being Done About It? The Journal of general psychology, 133(4), 401. https://doi.org/10.3200/GENP.133.4.401-420 

23 Esteban, S., Veliz, P., & Schulenberg, J. E. (2018). How collegiate fraternity and sorority involvement relates to substance use during young adulthood and substance use disorders in early midlife: A national longitudinal study. The Journal of adolescent health : Official publication of the Society for Adolescent Medicine, 62(3 Suppl), S35. https://doi.org/10.1016/j.jadohealth.2017.09.029

24 Ibid. 

25 Rosenbloom, C. (2019, March 11). New Concern on College Campuses: ‘Drunkorexia,’ a Combination Drinking and Eating Disorder. The Washington Post. https://www.washingtonpost.com/lifestyle/wellness/new-concern-on-college-campuses-drunkorexia-a-combination-drinking-and-eating-disorder/2019/03/08/093cf47c-4028-11e9-9361-301ffb5bd5e6_story.html 

26 Ibid.

27 Wombacher, K., Matig, J. J., Sheff, S. E., & Scott, A. M. (2019). "It Just Kind of Happens": College Students' Rationalizations for Blackout Drinking. Health communication, 34(1), 1–10. https://doi.org/10.1080/10410236.2017.1384351 

28 Ehman, A. C., & Gross, A. M. (2019). Acceptance and Commitment Therapy and Motivational Interviewing in the Treatment of Alcohol Use Disorder in a College Woman: A Case Study. Clinical Case Studies, 18(1), 36–53. https://doi.org/10.1177/1534650118804886

Stress Management for Students: Unveiling Coping Strategies & Creative Outlets

Adverse Effects of Stress

Stress is a feeling that most people experience at some point in their life. Students are especially prone to experiencing the negative effects of stress when they feel overworked, sleep deprived and overwhelmed. Symptoms of stress are demonstrated in our bodies, mental state, mood and behavior and have a prominent effect on our day-to-day lives. 

The Mayo Clinic notes that symptoms of stress can manifest in a variety of ways, such as:[1]

• Body - headache, fatigue, sleep problems

• Mood - anxiety, irritability, lack of focus/motivation, depression

• Behavior - over/undereating, angry outbursts, drug/alcohol misuse, social withdrawal 

It is important to be able to recognize the symptoms of stress in order to effectively manage the cause.[2] 

Common Stressors

Students encounter a number of ongoing stressors, which involve the typical day-to-day challenges they face. Both high school and college students commonly report experiencing continuous stress related to their education, specifically academic-related stress. Pascoe and Parker (2020) found that this stress stems from factors such as the pressure to achieve high grades and concerns about receiving poor marks.[3] A 2017 survey conducted by the Organisation for Economic Co-operation and Development (OECD) across 72 countries involving 540,000 student respondents aged 15-16 revealed that, on average, 66% of students feel stressed about receiving low grades and 59% worry that tests will be difficult. Additionally, the survey found that 55% of students experience high levels of anxiety regarding school testing, even when adequately prepared. Furthermore, 37% of students reported feeling “highly tense” while studying.[4] 

With the prominence of social media in the lives of today’s students, news and world events are more readily available, thus providing additional stress in the lives of students. Information about politics, school shootings, and war are readily available, adding additional stress in their lives as they perceive the world they live in as “unsafe.”[5] Additionally, media can push unhealthy and unrealistic body images as well as idealistic lifestyle expectations on young minds, warping their sense of reality and leaving them feeling inadequate in comparison. While it is important for students to be informed, today’s teens have much more information at their fingertips than ever before, thereby exacerbating their stress. Since the many pressures and events that incite feelings of stress often cannot be avoided, people engage in utilizing coping mechanisms; however, not all coping mechanisms are healthy.[6] 

Unhealthy Coping Methods

As stress levels continue to rise in student populations, a number of unhealthy coping mechanisms have become increasingly popular. Harvard Health (2012) notes that some common methods of dealing with stress involve doing activities that help one put aside their worries for some time (e.g., constantly sleeping, binge-watching television, alcohol consumption and taking illegal drugs.[7] New York University (2015) found that alcohol and marijuana were common relaxers utilized by students for temporary relief from the daily pressures in their lives.[8] Additionally, temporary relief tends to be found through over- or under-eating, smoking, and engaging in a whirlwind of social activities in an attempt to avoid facing their problems. Unfortunately, a buildup of stress can lead to a person lashing out at others and increased violent behavior. On the surface, these coping mechanisms may seem to offer relief; however, many of these actions are not effective at relieving pressure and can actually exacerbate the stress one already feels to a higher degree. Fortunately, there are a number of creative methods of coping with stress that have a positive effect on students.[9]

Effective and Creative Outlets

Art

Art can be used to mitigate feelings of stress and anxiety. Specifically, art therapy is a type of psychological intervention that utilizes various artistic mediums and the individual's creative expression to facilitate the therapeutic exploration and comprehension of emotions – ultimately resulting in the creation of artwork. It is both a natural and enjoyable way for students to manage their stress.[10] Research conducted by Zaidel (2014) on the influence of art and active creativity on the brain indicates that patients who engage in newly discovered creative outlets often experience elevated dopamine levels. Dopamine, a neurotransmitter frequently depleted in individuals suffering from anxiety, depression, and excessive stress, tends to increase through the practice of art therapy. As a result, art therapy emerges as a beneficial option for individuals dealing with high stress levels, as it can effectively raise dopamine levels and promote a sense of happiness and well-being in patients.[11]

Music

Another effective outlet for stress is music. Listening to music offers a stress-reducing effect by influencing both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. A study published by the Cambridge University Press (2021) indicates that music demonstrated a decrease in cortisol levels (a well-known biomarker of stress) and a reduction in sympathetic activity (reflected in lower heart rate and blood pressure).[12] 

Different compositional elements of music (e.g., melody, rhythm, tonality and frequency) seem to influence individual relaxation responses. While most studies have used classical music, these effects have been observed across various music genres. High-frequency music, particularly at 528 Hz, appears to play a significant role in stress relief. Lata and Kourtesis (2021) note that music with this frequency can lower cortisol levels and increase oxytocin levels, regulating stress response and social bonding.[13] 

Meditation

Meditative practices can also relieve stress experienced by students. The Mayo Clinic describes meditation as a simple and inexpensive method of relaxation that doesn’t involve any materials or equipment to participate. Meditation is classified as a form of complementary medicine that involves the connection between the mind and body. By engaging in meditation, individuals can achieve a profound sense of relaxation and cultivate a calm state of mind.[14] During meditation, one directs their attention to clearing away the influx of chaotic thoughts that often clutter the mind and contribute to stress. This practice has the potential to improve both physical and emotional well-being, fostering a sense of overall balance and tranquility. Meditation can serve as a tool for relaxation and stress management by redirecting one’s focus towards calming elements. Through meditation, one can develop the ability to maintain inner peace and a centered state of mind.[15] 

Furthermore, the benefits of meditation extend beyond the duration of the practice, itself. It can help individuals navigate their daily lives with a greater sense of composure. Yoga is a well known form of meditation utilized to cultivate both physical flexibility and mental tranquility through a sequence of poses and controlled breathing exercises. By engaging in specific postures that demand balance and concentration, attention is redirected away from the demands of a stressful day and towards the present moment.[16]

Exercise

Medical professionals consistently encourage maintaining an active lifestyle as the positive effects of physical exercise have been widely recognized (e.g., improving physical health and combating illness). Exercise is also regarded as essential for preserving mental well-being and can alleviate stress. The Anxiety and Depression Association of America (2022) notes that exercise has significant efficacy in reducing fatigue, enhancing alertness and focus, and improving overall cognitive function.[17] This research is supported by a 2015 study conducted van der Zwan et al., which compared a number of stress intervention methods and indicated physical activity was effective in reducing stress in the sample group.[18] This can be particularly beneficial when stress has depleted one's energy or ability to concentrate. When stress impacts the brain, affecting its numerous neural connections, the rest of the body experiences the repercussions as well. Exercise and other forms of physical activity stimulate the production of endorphins(a natural pain-relieving chemical in the brain) and also contribute to improved sleep, subsequently reducing stress levels.[19]

Psychotherapy

If creative outlets for stress reduction are not enough to mitigate the extreme levels of stress one is experiencing, psychotherapy can be used alongside or in place of creative outlets for stress reduction. Psychotherapy, also known as talk therapy, encompasses a range of therapeutic approaches designed to assist individuals in recognizing and modifying distressing emotions, thoughts and behaviors.[20] People often turn to psychotherapy when coping with intense or prolonged stress caused by work or family circumstances, the bereavement of a loved one, or challenges within relationships or family dynamics. Various forms of psychotherapy and interventions have demonstrated efficacy in addressing mental health disorders. Frequently, the treatment approach is customized to suit the particular case someone is experiencing. This involves identifying techniques for managing stress and formulating targeted problem-solving strategies.[21] 

There are a number of evidence-based approaches in psychotherapy that aid in dealing with stress:

• Cognitive Behavioral Therapy (CBT)

• Acceptance and Commitment Therapy (ACT)

• Mindfulness-Based Stress Reduction (MBSR) 

Both CBT and ACT are evidence-based psychotherapies utilized to help people manage symptoms of stress. CBT places greater emphasis on modifying or rectifying one's negative thoughts in order to relieve distress while ACT focuses more on transforming the way our personal experiences (e.g. thoughts, emotions, memories, and physical reactions) function and increasing our psychological flexibility, so that they no longer have a hold on us.[22,23] MBSR utilizes meditation principles to assist individuals in developing a heightened awareness of the influence negative thoughts have on their physical sensations.[24]

While beneficial for students, any of the afore-mentioned creative outlets and therapies can be useful for the general population experiencing stress, as well.

If you or someone you know is experiencing extreme stress and/or anxiety, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Mayo Foundation for Medical Education and Research. (2021). How Stress Affects Your Body and Behavior. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-symptoms/art-20050987  

2 Ibid.

3 Michaela C. Pascoe, Sarah E. Hetrick & Alexandra G. Parker (2020) The impact of stress on students in secondary school and higher education, International Journal of Adolescence and Youth, 25:1, 104-112, DOI: 10.1080/02673843.2019.1596823

4 Ibid.

5 Simmons, A. (2019). As Teen Stress Increases, Teachers Look for Answers. Edutopia. https://www.edutopia.org/article/teen-stress-increases-teachers-look-answers/ 

6 Columbia University. (2021). Is social media threatening teens’ mental health and well-being? Columbia University Irving Medical Center. https://www.cuimc.columbia.edu/news/social-media-threatening-teens-mental-health-and-well-being 

7 The President and Fellows of Harvard College. (2012, August 4). Watch Out for Unhealthy Responses to Stress. Harvard Health. https://www.health.harvard.edu/healthbeat/watch-out-for-unhealthy-responses-to-stress 

8 New York University. (2015). NYU study examines top high school students’ stress and coping mechanisms. NYU. https://www.nyu.edu/about/news-publications/news/2015/august/nyu-study-examines-top-high-school-students-stress-and-coping-mechanisms.html

9 Harvard Health

10 Sage Neuroscience Center. (2021, July 27). How Art Can Help Relieve Stress. Sage Neuroscience Center. https://sageclinic.org/blog/art-relieve-stress/#:~:text=How%20Can%20Drawing%20and%20Painting,%2C%20depression%2C%20and%20excessive%20stress  

11 Zaidel DW. Creativity, brain, and art: biological and neurological considerations. Front Hum Neurosci. 2014 Jun 2;8:389. doi: 10.3389/fnhum.2014.00389. PMID: 24917807; PMCID: PMC4041074.

12 Lata, F., & Kourtesis, I. (2021). Listening to music as a stress management tool. European Psychiatry, 64(S1), S609-S609. doi:10.1192/j.eurpsy.2021.1621

13 Ibid.

14 Mayo Clinic. (2022). Meditation: A simple, fast way to reduce stress. Mayo Foundation for Medical Education and Research (MFMER). 

https://www.mayoclinic.org/tests-procedures/meditation/in-depth/meditation/art-20045858

15 Ibid.

16 Ibid.

17 Anxiety and Depression Association of America. (2022). Physical Activity Reduces Stress. ADAA. https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/stress/physical-activity-reduces-st#:~:text=Exercise%20and%20other%20physical%20activity,your%20body%20to%20produce%20endorphins.

18 van der Zwan, J.E., de Vente, W., Huizink, A.C. et al. Physical Activity, Mindfulness Meditation, or Heart Rate Variability Biofeedback for Stress Reduction: A Randomized Controlled Trial. Appl Psychophysiol Biofeedback 40, 257–268 (2015). https://doi.org/10.1007/s10484-015-9293-x

19 Anxiety and Depression Association of America

20 U.S. Department of Health and Human Services. (2023). Psychotherapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/psychotherapies  

21 Ibid.

22 Guarna, J. (n.d.). Comparing ACT and CBT. Association for Contextual Behavioral Science. https://contextualscience.org/comparing_act_and_cbt#

23 Wersebe H, Lieb R, Meyer AH, Hofer P, Gloster AT. The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. Int J Clin Health Psychol. 2018 Jan-Apr;18(1):60-68. doi: 10.1016/j.ijchp.2017.09.002. Epub 2017 Oct 17. PMID: 30487911; PMCID: PMC6220909.

24 Johns Hopkins Medicine. (2023) Stress Busters: 4 Integrative Treatments. The Johns Hopkins University. https://www.hopkinsmedicine.org/health/wellness-and-prevention/stress-busters-4-integrative-treatments

Writing to Heal

A Basis in Bibliotherapy

The use of writing as a tool in the health field is not a new concept; it has roots in bibliotherapy, a form of therapy that began in the 5th century BCE. This therapy was based on the belief that literature could help people face the challenges that would arise in their daily lives, and was often used to treat melancholia (a condition of profound sadness and despair). It wasn’t until the 20th century that writing in therapy began to truly gain traction in the psychological world.[1]

Sigmund Freud, the founding father of psychoanalysis, is largely responsible for the growth of writing in therapy as a result of his 1907 presentation “Creative Writers and Day Dreaming” (which was eventually written and published). His speech bolstered the concept of writing as a therapy tool and it only continued to grow throughout the 1930s and 1940s, during which time the use of creative arts in therapy became popularized.[2] Currently, writing is one of the most commonly-used tools with patients in psychotherapy, even if it isn’t the focus of the therapy nor the core tool used.[3]

TYPES OF WRITING IN THERAPY

Writing can take several forms within a therapeutic setting. The first is free writing, which often comes in the form of journaling. When free writing, the client’s only instruction is to write what is on their mind; to put their thoughts on paper in whatever form they come in, without censoring or altering them.[4] Though this may seem basic, it’s entirely common for people to try and reject thoughts that they don’t find appealing. They often worry that, by acknowledging these thoughts, they’ll also be giving them credibility, or making them true.[5] However, repressing or denying thoughts instead of addressing them will only do more harm than good in the long run; thus, giving the client a space where they can express all of their thoughts (and easily reflect on them later) can be incredibly beneficial. 

Writing poetry is another often recommended outlet, for similar reasons. It provides a creative, positive avenue for a client to express their thoughts and emotions, and helps them channel even negative feelings into something productive.[6]

Letter writing is another common tool used in therapy. Essentially, the client is tasked with writing a letter; the recipient of the letter varies. It may be to themselves, to someone in their life they have unresolved issues with, or to a concept or issue that they’ve personified for the sake of the exercise. However, the letter will never actually be sent to anyone. Its purpose is to allow the client to communicate their feelings (on a given issue or person) to themselves more than to anyone else. By writing them down and expressing them in a way that would help the other person (whether they’re real or imaginary) understand their emotions and perspective, the client can gain a better understanding of their emotions on the matter.[7]

While it does not technically include writing, storytelling can also be used with young children in therapy in a manner very similar to (or even crossing over with) play therapy. One particularly famous example involves the use of dolls. In this exercise, the therapist gives their child client one or two dolls, and instructs them to tell the therapist a story using the dolls. In theory, the story the child tells using the dolls would be reflective of their own experiences, giving the therapist insight into the child’s understanding of and perspective on what they have gone through.

DISORDERS MOST-BENEFITED

Writing is commonly used to treat PTSD, anxiety and depression.[8] For all three psychological disorders, writing is helpful because it allows the patient to externalize their mental processes and emotions in a way that is productive and generally isn’t harmful to themselves or to others. Regarding PTSD, an example of writing therapy is demonstrated in a 2013 study by Lorenz et al.; they invited 70 women who experienced childhood sexual abuse to participate in five weekly 30-minute sessions that included writing therapy. In these sessions, participants would write about their traumas and sexual schemas. Then, at three different intervals—two weeks, one month and six months (post study) they were asked to complete questionnaires centered around their PTSD symptoms, depression, and sexual functioning. Not only did participants report fewer PTSD symptoms post-treatment, but those who wrote about their sexual schemas reported experiencing less sexual dysfunction.[9]

Writing can also be beneficial in treating anxiety. In 2020, the Tabriz University of Medical Sciences in Iran performed a study in which they administered three writing therapy sessions to pregnant women. Each week, they utilized writing therapy in different ways. In the first, the women were tasked with writing about concerns they had about their pregnancy and possible solutions. In the second, they were asked to write a story about their concerns, in which they applied the solutions they had brainstormed in the previous section. Finally, in the third, participants were led through a group discussion about their previous assignments. At the end of the study, the research team concluded that the women who had participated in writing therapy had much lower anxiety levels than the control group, despite having only experienced three sessions.[10]

Patients with depression can also benefit from writing therapy. In a 2014 study published in Cognitive Therapy and Research, two groups of undergraduate students were gathered and given separate tasks. The first was asked to engage in non-emotional writing (i.e., writing that does not focus on complicated emotions or traumatizing experiences). The second was asked to participate in emotional writing, with a special focus on emotional acceptance of traumatic experiences. At the end of the study, those who had engaged in emotional writing saw a reduction in their depressive symptoms, while those who had conducted non-emotional writing saw no change.[11]

Writing can also be used to treat issues that are not fully-fledged psychological disorders. When a person is looking to improve their self-esteem, process bereavement, find perspective or avoid relapses, their mental health provider may recommend incorporating writing into their treatment plan.[12] Writing is also frequently used with patients who have terminal or life-threatening illnesses. In addition to providing clients with an outlet for the undoubtedly complex, intense emotions they have about their condition, Murray (2002) notes that writing about one’s emotions and stress has been shown to improve immune functioning.[13]

ADDITIONAL BENEFITS OF WRITING THERAPY

There are numerous benefits to writing in therapy, including physical benefits. In addition to increasing immune function (though the exact explanation as to how has not yet been discovered),[14] Moy (2017) notes that writing has also been shown to lessen stress, lower blood pressure and can even improve liver function.[15] 

The benefits of writing extend beyond physical advantages. Students who engage in writing therapy often experience an improvement in their grades, likely in part because writing also strengthens a person’s memory (both in the sense of making them more apt to remember specific information and by improving their recall abilities). Writing also generally results in decreased symptoms of depression and reduced emotional distress, which can result in fewer missed days of work or school compared to those who don’t utilize writing therapy.[16]

Further, writing is a versatile tool that can be used in a variety of therapies, in one form or another. It also requires few resources, making it easily and readily available to clients.

LIMITATIONS

There are few disadvantages to writing therapy. Some patients will benefit with writing therapy more than others and some forms of writing will prove to be more effective than others, based on the individual. Therefore, it’s important to utilize different forms of writing until the one with greatest efficacy is determined. 

The biggest points of contention among psychologists regarding writing include: the discussion of venting vs. healing; and the risk of retraumatizing patients. Depending on the manner in which writing is utilized, a mental health provider may ask the patient to write about a traumatic experience that they endured. In doing so, the patient must, to some degree, relive the experience, and some psychologists worry that the process of reliving the trauma will only do the patient more harm than good.[17] Others argue that avoiding acknowledgment of the trauma is the real danger, and while the process of reliving the experience may be difficult or painful in the moment, the long-term relief will be worth the short-term struggle.[18]

If you’re interested in pursuing writing in therapy and exploring the psychological benefits of this modality, please reach out to a licensed mental health professional to discuss options and plan a course of action.

Contributed by: Jordan Rich

Editor: Jennifer (Ghahari) Smith, Ph.D.

1  Moy, J.D. (2017). Reading and writing one’s way to wellness: The history of bibliotherapy and scriptotherapy. New Directions in Literature and Medicine Studies, 15-30.  https://doi.org/10.1057/978-1-137-51988-7_2

2 Ibid.

3 Exploring Your Mind. (2018). Writing as a Therapeutic Tool.  https://exploringyourmind.com/writing-therapeutic-tool/

4 Tartakovsky, M. (2015). The Power of Writing: 3 Types of Therapeutic Writing. Psych Central. https://psychcentral.com/blog/the-power-of-writing-3-types-of-therapeutic-writing#1

5 Ibid.

6 Ibid.

7 Ibid.

8  Anderson, B. L., & Cyranowski, J. M. (1994). Women’s sexual self-schema. Journal of Personality and Social Psychology, 67(6), 1079–1100. https://doi.org/10.1037/0022-3514.67.6.1079

9  Lorenz, T. A., Meston, C. M., & Stephenson, K. R. (2013). Effects of expressive writing on sexual dysfunction, depression, and PTSD in women with a history of childhood sexual abuse: Results from a randomized clinical trial. The Journal of Sexual Medicine, 10(9), 2177–2189. https://doi.org/10.1111/jsm.12247

10  Esmaeilpour, K., Golizadeh, S., Mirghafourvand, M., Mohammad-Alizadeh-Charandabi, S., & Montazeri, M. (2020). The effect of writing therapy on anxiety in pregnant women: A randomized controlled trial. Iranian Journal of Psychiatry and Behavioral Sciences, 14(2). https://doi.org/10.5812/ijpbs.98256

11  Baum, E. S., & Rude, S. S. (2013). Acceptance-enhanced expressive writing prevents 

symptoms in participants with low initial depression. Cognitive Therapy and Research, 

37. 35-42. https://doi.org/10.1007/s10608-012-9435-x

12 Exploring Your Mind (2018)

13 Murray, B. (2002). Writing to Heal. Monitor on Psychology, 33(6), 54. 

https://www.apa.org/monitor/jun02/writing

14 Ibid.

15 Moy (2017)

16 Ibid.

17 Capozzi, B. (2021). The Benefits and Drawbacks of Therapeutic Writing. Step Up for Mental Health. 

https://www.stepupformentalhealth.org/benefits-and-drawbacks-of-therapeutic-writing/

18 Ibid.