TREATING BODY DYSMORPHIA: THE CASE FOR MORE RESEARCH

When Beauty Is the Beast

January 2019. My workouts get longer and my meals get smaller along with my waist. Subtract twelve pounds but the mirror still shows me a monster. Acne, dark spots, rolls of fat— I am a billboard displaying my worst nightmares. At least that’s what my brain tells me. Everything around me proceeds as normal: boys ask me out, girls ask me how, and everyone calls me beautiful. Why does my brain refuse to see me as I actually am? 

The DSM-5 characterizes body dysmorphic disorder (BDD) as a fixation on perceived imperfections in physical appearance that are insignificant or unnoticeable to others.[1] This occurs as a consequence of abnormal visual processing in the brain that results in an increased focus on minute details and an inability to see the bigger picture.[2] BDD often co-occurs with major depressive disorder (MDD) as well as with suicidal thoughts and tendencies. It is also associated with anxiety, social avoidance, neuroticism, and perfectionism.[3] About 1.7% to 2.9% of the general population is impacted by BDD, which is equivalent to about 1 in 50 people. In the US alone, approximately 5 to 10 million people have this disorder.[4] BDD impacts women more frequently than men— with women comprising roughly 60% of the impacted population.[5] However, BDD still remains quite under-diagnosed and the true prevalence may not be known at present.[6]

Photo credit: Sanjana Bakre

Current Treatments for BDD

The two most common treatments for BDD are cognitive behavioral therapy (CBT) and selective serotonin re-uptake inhibitors (SSRIs). Combining both is the most common method of treatment used today.[7] In terms of alleviating symptoms and how long effects last beyond completion of treatment, CBT appears to be the most effective and lasting treatment available. Continuous use of SSRIs is required to alleviate symptoms in the long run.[8] However, neither treatment has yet been proven to be both effective and permanent.[9]

Cognitive Behavioral Therapy (CBT) for Treating BDD

CBT techniques focus on curbing damaging behaviors and thoughts by helping individuals perceive themselves more holistically beyond small imperfections. This helps alter the abnormal visual processing caused by BDD that involves heightened focus on minute details. As it targets this key mechanism of the disorder, CBT remains the recommended treatment for BDD today.[10] Moreover, CBT encourages patients to face their fears— such as going out in public without concealing their perceived flaws— and ultimately aims to adapt patients’ belief systems to be more flexible and self-accepting.[11]  

Research suggests that CBT is moderately effective in treating BDD, both in terms of improvement and permanence: it has been found to reduce symptoms between 50-78% and last at least 2 months.[12] In a study by Wilhelm et al. (2014), after 24 weeks of CBT, the Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS) scores of all participants decreased by 30% or more; this margin that indicates that symptoms had “much improved”.[13,14] In another study by Rosen et al. (1995), after undergoing 8 weeks of CBT, participants scored significantly lower on the Body Dysmorphic Disorder Examination (BDDE); these scores remained constant even 4.5 months after treatment was stopped.[15] These results suggest that the effects of CBT are somewhat lasting, likely due to alterations to the negative belief systems and perceptions that directly reinforce BDD. 

However, there is a lack of research confirming that the positive effects of CBT last beyond 6 months.[16] Longitudinal observation in one study conducted by Krebs et al. (2017) supported the opposite notion: adolescents continued to have significant symptoms of BDD and were still at risk for related, dangerous behaviors a year after CBT was stopped.[17] Therefore, it can be reasonably concluded that CBT is, at best, moderately effective as it does not completely alleviate symptoms and appears to be rather short-term in its effects. Continuous CBT is required in order for BDD patients to remain symptom-free in the long-term.[18]

SSRIs for Treating BDD

SSRIs are antidepressant drugs that alleviate a majority of BDD symptoms by altering neurotransmission in the brain. They have been proven to be the most effective antidepressants for treating BDD.[19] SSRIs prolong the effects of the neurotransmitter serotonin by preventing its re-uptake in synapses, inducing feelings of positivity and relaxation.[20] These are generally prescribed to make BDD patients’ daily lives easier and to make them more receptive to CBT.[21]

SSRIs improve both the symptoms and the mechanisms of BDD, reducing anxiety and compulsive behaviors while also altering perceptions of flaws— as with most medication, it is an effective treatment but there is no scope for continuity of the positive effects after treatment is stopped.[22,23] According to research, SSRIs can result in reductions across all elements of the BDD-YBOCS.[24] Patients who took SSRIs also showed significant improvements in their scores on BDD modification of the Fixity of Beliefs Questionnaire for OCD, suggesting meaningful changes in their beliefs regarding physical appearance. These changes are important as they undermine the very maintenance mechanism of BDD.[25] These alterations likely occur in response to improvements in one’s overall mood as well as a reduction in obsessive thoughts.  However, there is a lack of research observing the long-term effects of SSRI treatment beyond 6 months, let alone what occurs after these medications are stopped. A study by Hollander et al. (2008) has been published on the effects of continuing treatment for 6 months and it was found that 8% relapsed and 60% did not improve further.[26] This highlights that while SSRIs may prevent relapse, it only causes improvements for a short period of time.[27] Overall, SSRIs can be considered extremely effective in alleviating symptoms of BDD; however, this effect is ephemeral so SSRIs must be taken continuously in order be considered a permanent treatment for BDD.[28] While SSRIs are considered fairly safe to take long-term, they also have adverse side effects such as weight gain, gastrointestinal issues, and sexual dysfunction. Additionally, there is a lack of empirical data identifying the impacts of taking these beyond 10 years, let alone indefinitely.[29,30]

The Future of BDD Treatment

Overall, both CBT and SSRIs alleviate symptoms— with SSRIs causing greater improvements— for a few months at least. Although SSRIs can technically continue to prevent symptoms if continuously taken, they don’t necessarily allow patients to remain non-reliant on treatment and their long-term side effects are relatively unknown. It appears as though CBT in conjunction with SSRIs, is the most effective existing treatment. 

Unfortunately, research by Rossell et al. (2017) suggests that these treatments only result in a 50-70% improvement because they do not address new findings regarding other mechanisms of BDD, such as abnormal connectivity between brain structures and correlations with GABA receptors.[31] Additionally, a lacuna in BDD-specific research has made it quite difficult to draw conclusions about the efficacy of existing treatments— there are less than 10 published studies investigating each of these treatments, and none of them explore their long-term effects beyond 6 months.[32] At present, more research into BDD treatment is needed not only to better evaluate the efficacy of current treatments, but also so that these can be further developed and optimized. Further research into the mechanisms of BDD can also potentially aid these efforts by providing more guidance in the development of new treatments. Given that BDD and its co-morbidities can severely interfere with people’s lives, future research efforts to inform and advance BDD treatments are essential. 

Contributed by: Sanjana Bakre

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

If you think you may be suffering from BDD, please reach out to a licensed mental health professional for guidance/assistance.

REFERENCES

1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

2  Feusner, J. D., Moody, T., Hembacher, E., Townsend, J., Mckinley, M., Moller, H., & Bookheimer, S. (2010). Abnormalities of Visual Processing and Frontostriatal Systems in Body Dysmorphic Disorder. Archives of General Psychiatry, 67(2), 197. https://doi.org/10.1001/archgenpsychiatry.2009.190

3 American Psychiatric Association (2013) 

4 Phillips, K. A. (n.d.). Prevalence of BDD. International OCD Foundation. Retrieved September 28, 2022, from https://bdd.iocdf.org/professionals/prevalence/#:~:text=Body%20Dysmorphic%20Disorder%20affects%201.7,United%20States%20alone%20have%20BDD

5 Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. 1997 Sep;185(9):570-7. doi: 10.1097/00005053-199709000-00006. PMID: 9307619.

6 Phillips, K. A. (n.d.). Who gets BDD? International OCD Foundation. Retrieved September 28, 2022, from https://bdd.iocdf.org/about-bdd/who-gets/

7 Hollander, E., Allen, A., Kwon, J., Aronowitz, B., Schmeidler, J., Wong, C., & Simeon, D. (1999). Clomipramine vs Desipramine Crossover Trial in Body Dysmorphic Disorder. Archives of General Psychiatry, 56(11), 1033. https://doi.org/10.1001/archpsyc.56.11.1033

8 Phillipou, A., Rossell, S. L., Wilding, H. E., & Castle, D. J. (2016). Randomised controlled trials of psychological & pharmacological treatments for body dysmorphic disorder: A systematic review. Psychiatry Research, 245, 179–185. https://doi.org/10.1016/j.psychres.2016.05.062

9 Beilharz, F., & Rossell, S. L. (2017). Treatment Modifications and Suggestions to Address Visual Abnormalities in Body Dysmorphic Disorder. Journal of Cognitive Psychotherapy, 31(4), 272–284. https://doi.org/10.1891/0889-8391.31.4.272

10 Phillipou et al. (2016)

11 Beilharz et al. (2017)

12 Ibid.

13 Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., … Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45(3), 314–327. https://doi.org/10.1016/j.beth.2013.12.007

14 Phillips, K. A., Hart, A. S., & Menard, W. (2014). Psychometric evaluation of the Yale–Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). Journal of Obsessive-Compulsive and Related Disorders, 3(3), 205–208. https://doi.org/10.1016/j.jocrd.2014.04.004

15 Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63(2), 263–269. https://doi.org/10.1037/0022-006x.63.2.263

16 Harrison, A., Cruz, L. F. D. L., Enander, J., Radua, J., & Mataix-Cols, D. (2016). Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 48, 43–51. https://doi.org/10.1016/j.cpr.2016.05.007

17 Krebs, G., Cruz, L. F. D. L., Monzani, B., Bowyer, L., Anson, M., Cadman, J., … Mataix-Cols, D. (2017). Long-Term Outcomes of Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder. Behavior Therapy, 48(4), 462–473. https://doi.org/10.1016/j.beth.2017.01.001

18 Ibid. 

19 Hollander et al. (1999)

20 National Health Service UK. (2021, December 8). Overview - Selective serotonin reuptake inhibitors (SSRIs). NHS UK. Retrieved September 22, 2022, from https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/overview/#:~:text=It's%20thought%20to%20have%20a,messages%20between%20nearby%20nerve%20cells

21 Greenberg, J. L., Wilhelm, S., Feusner, J., Phillips, K. A., & Szymanski, J. (2019, January 23). How is BDD Treated? International OCD Foundation. https://bdd.iocdf.org/about-bdd/how-is-bdd-treated

22 Phillips, K. A. (2005). The broken mirror: understanding and treating body dysmorphic disorder. Oxford University Press.

23 Phillips, K. A., & Hollander, E. (2008). Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach. Body Image, 5(1), 13–27. https://doi.org/10.1016/j.bodyim.2007.12.003

24 Ibid. 

25 Hollander et al. (1999)

26 Phillips et al. (2008)

27 Jain S, Grant JE, Menard W, Cerasoli S, Phillips KA. A chart-review study of SRI continuation treatment versus discontinuation in body dysmorphic disorder. Abstracts, National Institute of Mental Health NCDEU 44th Annual Meeting; Phoenix, AZ. 2004. p. 231.

28 Phillipou et al. (2016)

29 National Collaborating Centre for Mental Health (UK). Depression in Adults with a Chronic Physical Health Problem: Treatment and Management. Leicester (UK): British Psychological Society (UK); 2010. NICE Clinical Guidelines, No. 91.

30 Peterson A. (2019) New Concerns Emerge About LongTerm Antidepressant Use. Anxiety and Depression Association of America. Retrieved September 28, 2022, from https://adaa.org/sites/default/files/New%20Concerns%20Emerge%20About%20Long-Term%20Antidepressant%20Use.pdf

31 Beilharz et al. (2017)

32 Phillipou et al. (2016)

A Case for Mental Health Professionals in School: Ending the School to Prison Pipeline

School to Prison Pipeline

The school to prison pipeline refers to the practice and policies that schools enact that result in pushing school children out of classrooms and subsequently into the criminal justice system.[1] This path disproportionately affects minority students of color as well as students with disabilities.[2]

These life-changing negative effects are typically the result of short and long-term actions and include: an increased rate of being imprisoned; dropping out of school; and repeating a grade.[3] Policies (e.g., zero tolerance), practices (e.g., suspensions and expulsions) and the presence of police officers in schools have resulted in the arrest of cumulatively tens of millions of public-school students for non-serious issues such as bad grades, tardiness and disorderly conduct.[4] The removal of students from educational learning opportunities and displacement into the juvenile and criminal justice system creates life-changing negative effects.[5]

Zero Tolerance Policies

Zero tolerance policies mandate school officials to give students severe, punitive and exclusionary consequences in response to misbehaviors by students.[6] These punishments are typically predetermined and apply regardless of the circumstances surrounding an incident.[7]

Winter (2016) noted these policies are proven to not work, as they do not actually make schools safer; moreover, they lead to disproportionate discipline for students of color.[8] Research has found that suspension is ineffective at changing students’ behavior and has serious long-term repercussions as they fall behind, academically.[9] Bacher-Hicks (2020) explained that some examples of these long-term repercussions include: lower educational achievement; lower graduation rates; lower college enrollment rates; and higher involvement in the juvenile and adult criminal justice systems.[10]

School Resource Officers

School Resource Officers (SROs) are sworn law-enforcement officers with arrest powers who work within a school setting.[11] Washington & Hazelton (2021) explain that SROs were originally established to prevent/stop mass shootings; however, their main role has become one contributing to the negative long-lasting impacts of school children in the school to prison pipeline.[12] School Resource Officers often use aggressive policing (which are a set of strategies used by law enforcement) to control disorder and strictly punish all levels of deviant behavior.[13] Sawchuck (2021) noted SROs are more likely to use force, and often arrest, for non-serious issues such as bad grades, tardiness and disorderly conduct.[14] School Resource Officers also disproportionately target students of color and individuals with disabilities, as arrest rates of these two groups are 3.5% higher in schools with SROs compared to those without.[15] An excessive use of force negatively harms an individual mentally, emotionally and sometimes physically.

Mental health impacts within the school to prison pipeline

Roughly 22% of children in the US suffer from mental illness and many schools are not equipped with appropriate professionals or practices to address it. This disparity often leads to students with mental health problems being suspended, expelled or arrested based on poor policies.[16] Although Anderson (2022) notes that many children are not tested for developmental delays and disorders, mental health issues, and disabilities, social worker Marcia Gupta believes that there is a need to understand the root causes of a child’s behavioral issues.[17,18] While ADHD may be a cause of a student’s behavioral issues, Gupta educates school staff how the behaviors may be the result of trauma, anxiety, and/or depression.[19] Rates of depression and anxiety among kids aged 3-to-17 have increased over the past five years; in 2020, nearly 1-in-10 kids (9.2%) had been diagnosed with anxiety.[20] Rather than punishment, which can have lifelong consequences, Anderson explains that children should receive behavioral health services in educational settings as an early intervention.[21]

A 2019 Georgetown Center on Poverty and Inequality reported that 45% of girls apprehended in the juvenile justice system report at least five Adverse Childhood Experiences.[22] Adverse Childhood Experiences (ACEs) are traumatic events that occur before a child turns 18. These events can include physical and emotional abuse; neglect; caregiver mental illness; and household violence. Harvard University’s Center on the Developing Child indicates that the more ACEs that a child has, the more likely they are to suffer from negative effects such as heart disease, diabetes, poor academic achievement and substance abuse.[23] The experience of ACEs in addition to other traumatizing events (e.g., racism) can result in toxic stress.[24] Resulting in lifelong health problems, the inability to receive adequate resources (e.g., caregiver support) causes a child’s body to endure long lasting stress since their body is unable to stop the stress response normally.[25]

How do we improve?

Reforming zero tolerance policies would be a significant step towards solving the school to prison pipeline problem. This reform could include positive reinforcement (e.g., the encouragement of behaviors through rewards) making the positive behavior more likely to occur.[26] Positive reinforcement is effective in that it reinforces what the child is doing correctly instead of focusing on what the child is doing wrong.[27] Newman (2021) notes this has the potential to motivate students to engage in positive behaviors through incentivization of good choices.[28]

School resource officers who are ill-equipped to address mental health issues in students play a vital role in maintaining the school to prison pipeline. An alternative to SROs would be an investment in counselors, nurses, social workers and other professionals to provide the adequate support needed for students. Currently, 1.7 million students attend schools with police but no counselors; 3 million students are in schools with police but no nurses; 6 million students are in schools with police but no school psychologists; and 10 million students are in schools with police but no social workers.[29] School counselors, nurses, social workers, and psychologists act as first responders towards children who are sick, stressed, traumatized, may act out, or may hurt themselves or others.[30] The National Association of School Psychologists (2010) note that the presence of professionals, such as school psychologists, result in academic performance improvement as well as decreased behavior problems.[31]

By replacing school resource officers with mental health and health care professionals, students can enjoy greater stability and safety, better excel in their studies/are more likely to achieve greater educational achievements and experience overall better mental health throughout life.

Contributed by: Ariana McGeary

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

REFERENCES

1 What is the School-to-Prison Pipeline? (n.d.). Retrieved from ADL: https://www.adl.org/education/educator-resources/lesson-plans/what-is-the-school-to-prison-pipeline

2 DREDF. (n.d.). School-to-Prison Pipeline. Retrieved from Disability Rights Education & Defense Fund: https://dredf.org/legal-advocacy/school-to-prison-pipeline/

3 ACLU Washington. (2019). What are the impacts of suspension and expulsion?

Retrieved from ACLU: https://www.aclu-wa.org/docs/what-are-impacts-suspension-and-expulsion

4 Elias, M. (2013). The School-to-Prison Pipeline. Retrieved from Learning For Justice: https://www.learningforjustice.org/magazine/spring-2013/the-school-to-prison-pipeline#:~:text=The%20vast%20majority%20of%20these,enforcement%20are%20black%20or%20Hispanic.

5 American University. (2021). Who is Most Affected by the School to Prison Pipeline? . Retrieved from AU School of Education: https://soeonline.american.edu/blog/school-to-prison-pipeline#:~:text=The%20school%2Dto%2Dprison%20pipeline%20causes%20a%20disproportionate%20number%20of,more%20likely%20to%20be%20imprisoned.

6 Zero-Tolerance Policies and the School to Prison Pipeline. (2018). Retrieved from Shared Justice: https://www.sharedjustice.org/most-recent/2017/12/21/zero-tolerance-policies-and-the-school-to-prison-pipeline#:~:text=The%20%E2%80%9Cschool%20to%20prison%20pipeline,funnel%20students%20into%20this%20pipeline.

7 Ibid.

8 Winter, C. (2020). Amid evidence zero tolerance doesn't work, schools reverse themselves. Spare the Rod. Retrieved from: https://www.apmreports.org/episode/2016/08/25/reforming-school-discipline

9 Ibid.

10 Bacher-Hicks, A. (2020). Long-term Impacts of School Suspension on Adult Crime. CEPR.

Retrieved from: https://sdp.cepr.harvard.edu/blog/long-term-impacts-school-suspension-adult-crime#:~:text=%E2%80%9CSchools%20that%20suspend%20more%20students,and%20adult%20criminal%20justice%20systems.

11 Sawchuck, S. (2021). School Resource Officers (SROs), Explained: Their duties, effectiveness, and more . Retrieved from Education Week: https://www.edweek.org/leadership/school-resource-officer-sro-duties-effectiveness

12 Washington, K., & Hazelton, T. (2021). School Resource Officers: When the Cure is Worse than the Disease. Retrieved from ACLU Washington: https://www.aclu-wa.org/story/school-resource-officers-when-cure-worse-disease

13 Sawchuck, S. (2021)

14 Ibid.

15 Washington, K., & Hazelton, T. (2021)

16 Ibid.

17 Anderson, T. (2022). Disrupting the school-to-prison pipeline will reduce disparities for Kansans. Kansas Reflector. Retrieved from: https://kansasreflector.com/2022/08/04/disrupting-the-school-to-prison-pipeline-will-reduce-disparities-for-kansans/

18 McCoy, N. (2019). The school-to-prison pipeline is a public health crisis for youth of color; BU panel shows how to break the cycle. Center for Innovation in Social Work & Health. Retrieved from: https://ciswh.org/school-to-prison-pipeline-public-health-crisis-for-youth-of-color 

19 Ibid.

20 Anderson, T. (2022)

21 Ibid

22 Ojukwu, O. (2022). The Mental Health Impacts of the School-To-Prison Pipeline. EQ

Collective. Retrieved from: https://www.eqcollective.org/news/the-mental-health-impacts-of-the-school-to-prisonpipeline#:~:text=Mental%20Illness%20Within%20the%20School%2Dto%2DPrison%20Pipeline&text=According%20to%20a%202019%20report,in%20the%20prison%2Fjail%20environment.

23 What are aces? And how do they relate to toxic stress? Center on the Developing Child at Harvard University. (2020). Retrieved from: https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/

24 Ibid.

25 Ibid.

26 Scott, H., Jain, A., & Cogburn, M. (2021). Behavior Modification. StatPearls.

27 Use Positive Reinforcement. (n.d.). Retrieved from Familyeducation: https://www.familyeducation.com/life/positive-reinforcement/use-positive-reinforcement#:~:text=Positive%20reinforcement%20reinforces%20what%20the,%2C%20and%20natural%2C%20logical%20rewards.

28 Newman, P. (2021). How Positive Reinforcement Improves Student Behavior . Retrieved from Kickboard: https://www.kickboardforschools.com/pbis-positive-behavior-interventions-supports/how-positive-reinforcement-improves-student-behavior/#:~:text=Positive%20reinforcement%20is%20focused%20on,by%20incentivizing%20their%20good%20choices.

29 Blad, E. (2019). 1.7 Million Students Attend Schools With Police But No Counselors, New Data Show . Retrieved from Education Week: https://www.edweek.org/leadership/1-7-million-students-attend-schools-with-police-but-no-counselors-new-data-show/2019/03

30 Ibid.

31 National Association of School Psychologists. (2010). School Psychologists: Improving Student and School Outcomes. Retrieved from National Association of School Psychologists: http://www.gaspnet.org/Resources/Documents/SP%20improving%20outcomes.pdf

Examining Substance Use & Addictive Disorders: A Q&A with SAS Therapists

An Uncontrollable Use

Substance use disorder (SUD) is a mental disorder affecting one’s brain and behavior, leading to an uncontrollable use of substances such as drugs, alcohol or medications. Symptoms can range from moderate to severe, with the most severe form of SUD referred to as an addiction.[1]

The National Institutes of Health (NIH) note the prevalence of SUD among adults in the U.S.:[2]

• Nearly one-third of adults have alcohol use disorder at some time in their lives, but only about 20 percent receive treatment.

• 10 percent of adults have drug use disorder at some point in their lives, but only 25% receive treatment.

Further, nearly 6% of those aged 12+ experienced prescription psychotherapeutic drug misuse in 2020.[3]

Comorbid conditions tend to present more in those with SUD, although research has not yet found concrete causal relationships among them. Co-occurring disorders may include: anxiety disorders, depression, attention-deficit hyperactivity disorder (ADHD), bipolar disorder, personality disorders, and schizophrenia. In the event of comorbid conditions, treatment for one disorder may be compounded and more difficult, though is still achievable.[4]

Compared to those without drug use disorder, individuals experiencing drug use disorder are:[5]

• 1.3 times as likely to experience clinical depression

• 1.6 times as likely to have post-traumatic stress disorder (PTSD)

• 1.8 times as likely to have borderline personality disorder (BPD).

Generally, it is better to treat the SUD and co-occurring mental disorder together, not separately. Thus, health care providers need to conduct full evaluations and provide a treatment plan based on one’s specific situation, in regards to their: age, misused substance and comorbid mental health disorder(s).  Both Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) have been found to be effective in treating substance use disorder.[6]

Q&A

SAS THERAPISTS DISCUSS SUBSTANCE USE DISORDER AND EFFECTIVE TREATMENT MODALITIES

1. How does someone even become aware that they have a problematic substance/alcohol use disorder/addictive disorder versus simply enjoying ____ to relax/unwind on a frequent basis? How does someone know when it’s time to seek assistance?

“Awareness of alcohol or substance use disorder or an addictive disorder (e.g. gambling, shopping, etc.) often comes as a result of some unwanted consequence related to the behavior - for many people this looks like a DUI, concern expressed from a loved one, physician, employer, etc., a negative test result from the doctor, or just feeling so crappy the next day that you start to wonder if the substance is worth the pain. It could be an incredible amount of debt, being kicked out of a casino, or having your credit cards maxed out and shut off/things going to collection. People also become more aware of the behavior as problematic when they try to stop and can't seem to stick to that goal. It freaks them out. Generally speaking, if you're worried you might have a problem, there's a good chance you do!

It's also important to note that using a substance to ‘unwind on a frequent basis’ in and of itself is problematic - what happens if you don't use this substance? What do you feel? If you can't tolerate your thoughts or emotions or physical sensations without using a substance to ‘unwind,’ it might be a good time to check in with a therapist.” (Jennie Ketcham Crooks, LICSW, MSW)

“This is a question frequently asked, both by those who use substances themselves and concerned loved ones. There are some aphorisms from the recovery world I often quote when helping to answer the question, including: ‘If you have to control it, it is already out of control.’ While of course this isn’t absolute, it can be a helpful realization that even minor things like counting drinks or scheduling use (‘I only use on weekends’, etc.) are not common in actual recreational users. It can be a cue for us and friends/family that the ‘control’ is gone if we are talking about controlling, so that cue can lead to seeking assistance. It is a helpful reminder that merely seeking assistance is not admitting addiction or signing-on for lifetime abstinence. Many folks today are trying on a trend – with regard to alcohol – called ‘sober curious’ for instance, which highlights a period of sober time with an attention to what is lost and gained without the presence of a drug (including alcohol) in their lives. In all, seeking assistance or merely asking questions (Google can be our friend!) is unlikely to be harmful. The more you know, right?!” (Kate Willman, MA, LMHCA, HCA)

2. In your experience, what are the biggest obstacles that someone has to overcoming a substance/alcohol use disorder/addictive disorder? How can they best overcome those obstacles?

“A major obstacle is the way in which society normalizes the use of alcohol and marijuana in particular - we think as if we ‘should’ be able to ‘drink normally,’ and when we fail to do so, it is pretty crushing. So we try and try again, and fail and fail again. Yet, the biggest obstacle to overcome is the tolerance of uncertainty; we don't know if you'll ever use again (That is, not until you use! Then we know!). Intolerance of uncertainty may be one contributing factor to why the relapse rates are so high. If one cannot tolerate the uncertainty about when they will use again, the only way to gain certainty is to use.” (Jennie Ketcham Crooks, LICSW, MSW)  

“The first ‘big obstacle’ that comes to mind is that drugs work. That may sound a bit odd, but: it’s true! The substances themselves will always be potent, will always have a desired effect on neurotransmitters at various levels, and are likely to always be made available in one way or another. In fact, some addictive substances are even legal to obtain. Therefore – in part to account for the assurance that drugs work – the next biggest obstacle most folks must overcome is their own desires to keep using. Again, this might sound odd to an outsider, but many addicts even in long-term recovery readily admit that if they could still use successfully, they would! So a person might have every desire in the world to stop using, and they can still retain some desire to keep using. Behavioral addictions like gambling or pornography use are similar in that the process or ‘chase’ of the behavior stimulates neurotransmitters in much the same way as a substance would.

One of the best ways I’ve seen others face and overcome this obstacle is through mutual support. Whether friends, family, professionals (like a therapist), or simply peer support from other people who have struggled with substance use or behavioral addictions… most people simply cannot do it alone. Many people today have also been able to find help online, through anonymous forums, meetings and/or social media. In the end, however, only the individual will be able to decide for themselves when ‘enough is enough’.” (Kate Willman, MA, LMHCA, HCA)

3. In what ways has the pandemic affected substance/alcohol use disorder/addictive disorder (rates, types, recovery) that you personally have witnessed in practice?

“Many people use substances or alcohol to ‘feel better’ - socially, it's been a way to connect (‘let’s grab a beer!’), physiologically it depresses your system (Anxious AF? Let’s grab a beer!), and the pandemic has been a context in which many people have needed social connection and experienced increases in anxiety (germs everywhere folks).” (Jennie Ketcham Crooks, LICSW, MSW)

“The pandemic seemed to exacerbate existing problems and / or introduce new anxieties for people. Many of our best, most natural coping mechanisms were unavailable to us, including – for instance – the live support of family and friends, the release, productivity + enjoyment of the workplace, and various hobbies enjoyed both socially or alone. And all of this at a time when we needed to cope more than ever. The already easy access to legalized substances like alcohol and cannabis became even easier via delivery programs in many areas, and so some people came to rely on use as a coping mechanism in the absence of others.

The two-or-so years of pandemic saw a decrease in coping outlets coupled with an overall increase in anxiety and depression (amidst other social, economic and political stressors). To boot, many people found themselves isolated. In other words, a prime opportunity for addiction issues to flourish, and since addiction already breeds isolation, a lack of social accountability encouraged isolation in the pandemic even further.” (Kate Willman, MA, LMHCA, HCA)

4. Would any specific psychotherapeutic modality be better-suited for someone battling these disorders than others?  If yes, which would you recommend and why?

“I think that any therapy that supports a client to identify their values and take committed action in alignment with those values will help them tolerate the distress of overcoming an substance or addictive disorder. I often talk about substances/alcohol or addictive behaviors as a solution to some problem, so knowing what's important to you in this life can help increase your motivation and your distress tolerance; chances are if you've quit a substance or alcohol (or gambling or shopping), whatever problem substances or alcohol solved will still be there. Ultimately, behavioral therapy will be an important component of treating substance and addictive disorders because your behavior will be required to change.” (Jennie Ketcham Crooks, LICSW, MSW)

“There is clinical research to support all types of different modalities for treating addiction.

The first that comes to mind specifically is Dialectical Behavioral Therapy (DBT) for its focus on skills to promote and practice emotional regulation, mindfulness, and tolerance for distress.

Acceptance and Commitment Therapy (ACT) combined with harm-reduction practices also comes to mind as a frequently used treatment as it does not focus on symptom reduction as an outcome. This can aid in recovery from or re-evaluation of a person’s relationship with drugs in that it removes focus on the substances and/or behaviors themselves and instead brings focus back to the person themselves.

Several variations on psychodynamic therapy have also been seen in addiction treatment, including existential and narrative therapeutic approaches.

Finally, people struggling with addiction – both behavioral and with substances – are still people, right? And their use is just a symptom of what are much larger problems. The person-centered approach can assist in a practitioner’s ability to use the best modality when treating those with use issues while also taking into account the presence of comorbid conditions.” (Kate Willman, MA, LMHCA, HCA)

5. Do certain comorbid mental health conditions appear more prevalent than others in those with these substance/alcohol use disorders?  Do some conditions make treatment more difficult?

“We see a high comorbidity between social anxiety and alcohol use disorder, largely related to what I noted in question 3 - when we feel nervous about social engagement, it can be easy to ‘grab a beer.’ While beer makes that anxiety go away temporarily, it ends up reinforcing an unhelpful learning pattern wherein the person ‘learns’ that beer is what kept them safe in the social engagement (versus learning that social engagement - and the experience of anxiety! - is a safe activity). That learning then says, ‘I must drink beer EVERY time I engage socially.’” (Jennie Ketcham Crooks, LICSW, MSW)

“The observable correlations between mental health issues and substance abuse are many.

First, the most common mental health issues such as depression, anxiety, etc. can lead to use or abuse of substances as a form of neutralizing discomfort (sometimes colloquially known as ‘self-medicating’). We see similar patterns in those experiencing behavioral addictions. Second, substance use itself can contribute to the experience of one or more symptoms of mental health issues – including depression, anxiety, suicidal ideation, psychosis, obsessive thoughts, etc.

Even further, there is substantial evidence that neurological changes can occur as a result of substance use, depending on frequency, duration + severity of use, as well as what substances are used and at what age(s) use begins. There are often correlations between substance use and mental health symptomology that are etiologically indistinguishable, i.e.: there is often a reciprocity between mental health issues and substance use issues that can make it difficult to discern the specific dynamics between them, let alone causation or source of either or both.

This is all to say that there are many possible comorbid conditions – especially those in the mental health realm – that make treating addiction more difficult. Additionally, a holistic perspective shows us that this generally means the life of the client is more difficult, and we should do our best to help mitigate confusion or shame in these cases. There are certainly some conditions we see more often than others – anxiety, depression, chronic pain, and various forms of trauma – however, this might be less correlated to addiction and more because these are prevalent conditions anyway.” (Kate Willman, MA, LMHCA, HCA)

6. Can you give an example of how you may guide someone in therapy who wants to overcome a substance/alcohol use disorder/addictive disorder? 

“If someone is seeing me specifically for addiction, we will begin with a practice of noting - with gentle curiosity - the behaviors they'd like to question. We gather data, do some values mining, and a functional assessment: Is this behavior moving you closer to or further away from a meaningful life. Then, depending on that result, we make some changes and commit to action. After a period of treatment, and after you see the changes happening in your life, we will do a course of mindfulness-based relapse prevention.” (Jennie Ketcham Crooks, LICSW, MSW)

“I would start by assessing for co-occurring disorders and then – if they are present – do my best assess which has a higher acuity and therefore probably requires attention first (this may or may not be the use itself). I’d also assess a client via the Stages of Change model to attempt to decipher ‘how ready’ they are to stop using. For instance, if a person is in ‘precontemplation’, we wouldn’t want to start jumping into recovery strategies. Once I’ve assessed where someone is in the process, we can collaborate on options to move forward. Sometimes a client needs support, needs to experience trust and empathy before they are willing to face the big world ahead of them without their drug or behavior of choice. Therapy, thankfully, is a great place to receive these, and even if a strong desire to change isn’t first apparent, it can develop over time through an informed and cooperative relationship.” (Kate Willman, MA, LMHCA, HCA)

7. Is there anything else you’d like to share with those interested in learning more about treatment and/or may be battling substance/alcohol use disorder/addictive disorder, themselves?

“Now, more than ever, there is more information about [and less stigma surrounding] the prevalence of substance use issues and the insidious nature of the disease of addiction. For those readers who don’t, themselves, identify as struggling with either of these issues, I urge you to become informed anyway, because the likelihood that you or someone you know will at some point face one or more of these issues is essentially guaranteed.

Support, accountability, empathy, and inclusion are paramount in treating the very real (and, too often, fatal) diseases of substance abuse + mental illness. We can all help by informing ourselves and others about the perils of addiction, the resources available for recovery, the universality of mental health issues, and the reality that love and understanding are key in facing these successfully.” (Kate Willman, MA, LMHCA, HCA)

Contributed by: Jennifer (Ghahari) Smith, Ph.D.

Jennie Ketcham Crooks, LICSW, MSW & Kate Willman, MA, LMHCA, HCA

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

For more information, click here to access an interview with Psychiatrist Lantie Jorandby on Addiction Recovery.

Additionally, you may click here to access an interview with Psychologist Robyn Walser on Trauma & Addiction.

REFERENCES

1 National Institutes of Mental Health (NIH). (n.d.) Substance use and co-occurring mental disorders. (accessed 9-20-2022) https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health#:~:text=A%20substance%20use%20disorder%20(SUD,most%20severe%20form%20of%20SUDs 

2 National Institutes of Mental Health (NIH). (n.d.) 10 percent of US adults have drug use disorder at some point in their lives. (accessed 9-21-2022) https://www.nih.gov/news-events/news-releases/10-percent-us-adults-have-drug-use-disorder-some-point-their-lives

3 NIH: National Institute on Drug Abuse. (n.d.) What is the scope of prescription drug misuse in the United States? (accessed 9-21-2022) https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse 

4 NIH. Substance use and co-occurring mental disorders.

5 NIH. 10 percent of US adults have drug use disorder at some point in their lives.

6 NIH. Substance use and co-occurring mental disorders.

Dental Anxiety: Strategies to Mitigate Discomfort & Fear Of the Dentist’s Office

The Prevalence of Dental Anxiety

The high-pitched whirling sound of the drill… that unique medicinal smell… the pain from that one time (or many times) before… Dental anxiety. If that first sentence made you uncomfortable, you’re not alone. Research touts that nearly half of the population has dental anxiety. Hill et al., (2009) found that approximately 36% suffer from dental anxiety, with an additional 12% experiencing extreme dental fear.[1] Previously, in 2006, Kamin et al., reported that between 50 and 80% of adults in the United States have some degree of dental anxiety, ranging from mild to severe. More than 20% of dentally anxious patients do not see a dentist regularly, and anywhere from 9 to 15% of anxious patients avoid care altogether.[2] Resulting in dental avoidance, serious repercussions in one’s oral health[3] and subsequent psychological and physical health can occur. 73% of respondents in a 2004 study by McGrath and Bedi noted that their oral health directly affected their quality of life.[4]

Coriat first defined dental anxiety in 1946 as, “an excessive dread of anything being done to the teeth” with “any dental surgery, no matter how minor, or even dental prophylaxis, may be so postponed or procrastinated that the inroads of disease may affect the entire dental apparatus”. Further, Coriat noted that this fear fell under the category of “anticipatory anxiety” as it stems from a fear of real danger and an anticipated unknown danger.[5,6] While the terms “dental fear” and “dental anxiety” have been used interchangeably, “dental phobia” is a more extreme manifestation. Lautch (1971) defined dental phobia as, “A special kind of fear, out of proportion to the demands of the situation, which will not respond to reason, is apparently beyond voluntary control and leads to avoidance of dental treatment where this is really necessary”.[7,8] A 2014 study by Randall et al., compared the prevalence of fears and phobias of nearly 2,000 individuals. Among the top fear mentions included: fear of snakes (34.8%); fear of physical injuries (27.2%); and dental fear (24.3%).[9]

Manifestations of Dental Anxiety & Phobia

Dental anxiety manifests in both physical and psychological responses. Physiological impacts commonly include signs and symptoms of the fright response (e.g., feelings of exhaustion following a dental appointment). Cognitive impacts tend to include a combination of negative thoughts, beliefs, and fears.[10]

Milgrom et al., (1995) identified four different groups of anxious patients, based on their origin, or source, of fear:[11]

1) anxious of specific dental stimuli

2) distrust of the dental personnel

3) generalized dental anxiety

4) anxious of catastrophe.

Common fears associated with dental anxiety include:[12]

• fear of pain

• fear of blood-injury fears

• lack of trust or fear of betrayal

• fear of being ridiculed

• fear of the unknown

• fear of detached treatment by a dentist or a sense of depersonalization

• fear of mercury poisoning

• fear of radiation exposure

• fear of choking and/or gagging

• a sense of helplessness in the dental chair

• a lack of control during dental treatment.

Those with dental phobia avoid going to the dentist and tend to only go when extreme pain forces them to.

Common signs of dental phobia include:[13]

• Trouble sleeping the night before a dental appointment.

• Nervous feelings that worsen in the dentist’s waiting room.

• Being unable to enter the dentist’s office.

• Crying and/or being physically ill at the thought of visiting a dentist.

Source: SeattleAnxiety (Instagram)

 DEVELOPMENT OF DENTAL FEAR

Dental anxiety may develop during any point in one’s life and due to a multitude of reasons.

Research highlights commonality between childhood experiences as an indicator of dental anxiety or phobia. Locker et al. (1998) studied the age of onset of dental anxiety in a survey of 1,420 adult participants: 16.4% were assessed as being dentally anxious; half of whom reported that their dental fear started in childhood.[14] 

A 2002 regression analysis noted a significant relationship between child dental anxiety and the number of extractions a child had experienced, suggesting that one of the causes of dental anxiety is invasive dental treatment. Conversely, ten Berge et al. found that children who had experienced more non-invasive check-up visits before their first curative treatment reported low levels of dental fear.[15] Beaton et al., (2014) suggest that the longer a child continues to have positive experiences when visiting the dentist, the less likely they are to become dentally fearful if/when they do eventually have a negative experience (i.e., latent inhibition).[16] Similarly, Oosterink et al., (2009) found that anticipation and expectations matter; if a patient expects pain during a scaling procedure, they are more likely to report higher anxiety levels.[17]

The role of memory is of particular importance regarding one’s dental experiences. Kent (1985) studied dental patients’ memory of pain by comparing: patients’ remembered pain 3 months after treatment with a)their expected pain and b) their experienced pain. Results indicated a closer association between remembered and expected pain than there was between remembered and experienced pain. Kent hypothesized that inaccurate memories of pain experienced during treatment may be leading to the continuation of dental anxiety in some patients.[18]

In 2011, Humphris and King examined the impact of previous distressing experiences of 1,024 that completed the Modified Dental Anxiety Scale (MDAS) and an assessment of their susceptibility (Level of Exposure-Dental Experiences Questionnaire; LOE-DEQ). Humphris and King found that 11% of the sample reported high dental anxiety. Respondents noted they most-feared local anesthetic injections and those who reported a previous distressing experience were 2.5 times more likely to experience high dental anxiety.[19,20]

Previous assault experiences also impact one’s likelihood of developing dental anxiety. Humphris and King’s study found sexual assault victims were almost two and a half times more-likely to report high dental anxiety. Similarly, Leeners et al. found that women who had been previously sexual assaulted reported anxiety related to lying flat in the dental chair, as well as a more pronounced gagging reflex.[21,22]

Dental anxiety can also develop vicariously; this occurs when one indirectly learns behavior and thought-patterns from role models (e.g., family members or peers) or from external sources (e.g., the media).[23] Themessl-Huber et al. (2010) conducted a systematic review and meta-analysis of 43 experimental studies about parental and child dental fear. They confirmed a significant relationship between child and parental dental fear, with parental dental anxiety significantly predicting a child’s subsequent dental anxiety.[24,25] Similarly, Locker et al. found that 56% of participants who reported an onset of dental anxiety during childhood had a parent or sibling who also suffered anxiety about dental treatment.[26] Additionally, Öst (1987) reported that child-onset phobias are more likely to develop through vicarious learning compared to phobias developing in adulthood.[27]

Those with dental anxiety may fall into a vicious cycle regarding their oral health care. This hypothesis, first proposed by Berggren in 1984, suggests that:[28]

• dental anxiety leads to avoidance of dental care

• avoidance results in neglect of dental treatment

• neglected dental treatment leads to subsequent poor oral health

• as one’s oral health declines, a person becomes more anxious and fearful of the expected pain they will encounter to fix said issues

• the increased anxiety/fear leads to greater avoidance of dental care.

The vicious cycle becomes compounded by feelings of embarrassment and shame at the delay in addressing oral health issues.[29] Unfortunately, as the cycle continues, dental issues typically worsen and create more extensive issues.[30-32]

In 2013, Armfield’s study supported the notion of this vicious cycle. Examining the dental anxiety and frequency of dental visits and treatment needs in 1,036 dentate Australians, he found that 39% of people with moderate to high dental fear avoid the dentist due to said fear.[33]

Overcoming Dental Anxiety

Research has found several ways that dentally-anxious patients can achieve lower levels of anxiety.

Depending on the dentist’s expertise and experience, degree of dental anxiety, patient characteristics, and clinical situations, dental anxiety can generally be managed by:[34]

• psycho-therapeutic interventions

• pharmacological interventions

• a combination of both.

Psychotherapeutic interventions are either behaviorally or cognitively oriented, and recently, the use of cognitive behavior therapy (CBT) has been shown to be highly successful in the management of extremely anxious and phobic individuals. Pharmacologically, patients can receive oral or inhaled sedation, or general anesthesia.

The following specific interventions/modifications may be helpful in reducing one’s anxiety in dental office settings:

Rapport & Trust Building – A positive patient–dentist relationship is of utmost importance in lessen one’s dental anxiety. Two-way communication is essential and dental staff should listen carefully in a calm, composed, and nonjudgmental way.[35] Dentists should fully describe any dental issues, possible treatment options, and preventive procedures. Further, patients should be encouraged to ask questions about what will occur/the treatment plan and should be kept informed both before starting a procedure as well as during the procedure.[36] By maintaining openness and honesty, rapport will grow as well as increasing the patient’s confidence in their dentist.[37]  

Maintaining Control – As afore-mentioned, knowing what will happen (and when) during a dental procedure is essential to reducing one’s anxiety. Giving the patient a chance to feel that they are in control of the treatment procedure is of utmost importance; this can happen by both choosing what treatment they want to happen as well as by increasing interactions with their dentist. Such interactions can come in the form of signaling to the dentist or dental hygienist to stop the procedure if the patient is under duress or in pain; pre-determined signals (e.g., raising one’s hand or pressing a button the office provides) increases a patients’ sense of control and trust in their dentist. Once a patient initiates a signal, the dentist or hygienist should immediately stop the procedure, as failure to do so will breach the trust relationship and once-again increase the patient’s anxiety levels.[38]

Dental Office Ambience – The ambience of the dental office can play a significant role in initiating or reducing dental fear and anxiety. Every staff member is crucial in creating a pleasant and calming atmosphere in the dental office. To foster patients being comfortable, staff should be positive and caring, and speak in unhurried, concerned tones. Soft music and warm lighting is also helpful in creating a calming atmosphere. Distractions such as artwork and reading material are also helpful in reducing patients’ anxiety levels.[39] Further, the more distanced a patient is from treatment rooms also helps: patients can be asked to wait in their car or outside of the building until the time they can be seen by medical staff.

Research has found aromatherapy to be efficient in managing moderate anxiety.[40-42] Aromatherapy is another effective approach to improving dental office ambiance, wherein essential oils of aromatic plants are used to produce positive effects through the sense of smell. Introducing pleasant ambient odors (e.g., lavender) to the dental environment can also help to reduce anxiety by masking the medicinal, anxiety-inducing smells present in a dental office.

Hydration without Caffeine – Maintaining adequate hydration is essential to feeling one’s best mentally and physically. However, dentally-anxious patients should avoid caffeine the day of dental office visits/procedures as caffeine can worsen one’s dental anxiety by increasing overall anxious feelings and agitation.[43]

Guided Imagery - Anxiety-provoking stimuli (e.g., the sound of the dental drill or medicinal smell of the office) lead to physical tension, which increases one’s perception of anxiety. Deep breathing and muscle relaxation techniques can lessen these physical responses. Guided imagery is a type of “deliberate daydream” utilizing all of one’s senses to create a focused state of relaxation and a sense of physical and emotional well-being. In this mind–body exercise, people develop a mental image of a pleasant, tranquil experience.[44] The mental image can be somewhere imagined or based on pleasant and calming memories. During guided imagery, a person should create a scenario full of specific, concrete details, along with sound, smell, and colors of the scene[45] so that they feel fully submersed in their daydream. Research has found guided imagery to be affective in the treatment of distress, mood, and anxiety symptoms associated with chronic pain, social anxiety disorder, attention deficit/hyperactivity disorder (ADHD), and cancer pain.[46,47]

Listening to Music - Music has been shown to influence human brain waves, leading to deep relaxation that alleviates pain and anxiety. The utilization of listening to music incorporates a combination of relaxation and distraction that reduces the activity of the neuroendocrine and sympathetic nervous systems. This method has been found to be successful in both pediatric and adult dental patients.[48,49]

PEDIATRIC DENTAL ANXIETY

It is normal for children to be fearful of the unknown, or of being away from their caregivers and they might express their fears by crying or having a temper tantrum. To help a child’s dental visit go more smoothly and with less agitation, the Cleveland Clinic offers the following suggestions:[50]

• Tell your child about the visit and answer their questions with simple, to-the-point answers. If they have more complex or detailed questions, let the dentist answer them. Pediatric dentists and hygienists are trained to describe things to children in easy-to-understand and non-threatening language.

• Don’t tell your child about any unpleasant dental experiences you’ve had. If you act anxious, your child might pick up on that and feel anxious too.

• Stress to your child how important it is to maintain healthy teeth and gums. Make sure they understand that the dentist will help them with this.

• Get your child an age-appropriate book, which depicts characters going to the dentist for the first time.

• Do not promise a reward for going to the dentist.

• Let your child’s dentist know that the child is especially fearful so they will be able to address your child’s anxieties and ease their fears.

A sensory-adapted dental environment (SDE) might also be effective in reducing anxiety and inducing relaxation. In 2007, Shapiro et al., found that utilizing a “Snoezelen” dental environment for pediatric patients was especially helpful for dentally-anxious children.[51] Comprised of dimmed lighting, soothing music, and a special Velcro butterfly vest that hugs the child, a calming, deep-pressure sensation develops. Both behavioral and psychophysiological measures of relaxation have been found to improve significantly in the SDE compared with a conventional dental environment.[52,53]

If you would like to try incorporating cognitive-behavioral therapy (CBT) techniques into reducing your dental anxiety, you may reach out to a licensed mental healthcare provider specializing in that treatment modality.

Contributed by: Jennifer (Ghahari) Smith, Ph.D.

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

References

1 Hill KB, Chadwick B, Freeman R, et al. Adult Dental Health Survey 2009: relationships between dental attendance patterns, oral health behaviours and the current barriers to dental care. Br Dent J. 2013;214:25–32.

2 Kamin V. Fear, stress, and the well dental office. Northwest Dent. 2006;Mar-Apr; 85(2):10-1,13,15-8.

3 Freeman R. Barriers to accessing dental care: patient factors. Br Dent J. 1999;187:141–144.

4 McGrath C, Bedi R. The association between dental anxiety and oral health-related quality of life in Britain. Community Dent Oral Epidemiol. 2004;32:67–72.

5 Coriat IH. Dental anxiety: fear of going to the dentist. Psychoanal Rev. 1946;33:365–367.

6 Beaton, L., Freeman, R., & Humphris, G. (2014). Why are people afraid of the dentist? Observations and explanations. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 23(4), 295–301. https://doi.org/10.1159/000357223

7 Ibid.

8 Lautch H. Dental phobia. Br J Psychiatry. 1971;119:151–158.

9 Randall C, Shulman P, Crout R, McNeil D. Gagging and its associations with dental care-related fear, fear of pain and beliefs about treatment. J Am Dent Assoc. 2014 May;145(5):452-457.

10 Cohen SM, Fiske J, Newton JT. The impact of dental anxiety on daily living. Br Dent J. 2000;189(7):385–390.

11 Milgrom P, Weinstein P, Getz T. Treating Fearful Dental Patients: A Patient Management Handbook. Seattle: Reston Prentice Hall; 1995.

12 Appukuttan D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, cosmetic and investigational dentistry, 8, 35–50. https://doi.org/10.2147/CCIDE.S63626

13 Cleveland Clinic. (n.d.) Nervous About Going to the Dentist? Try These Tips to Ease Dental Anxiety. (accessed 9-15-2022) https://health.clevelandclinic.org/nervous-about-going-to-the-dentist-try-these-tips-to-ease-dental-anxiety/

14 Locker D, Liddell A, Dempster L, et al. Age of onset of dental anxiety. J Dent Res. 1999;78:790–796. 

15 ten Berge M, Veerkamp JSJ, Hoogstraten J. The etiology of childhood dental fear: the role of dental and conditioning experiences. J Anxiety Disord. 2002;16:321–329.

16 Beaton, L., Freeman, R., & Humphris, G. (2014).

17 Oosterink FM, de Jongh A, Hoogstaten J. Prevalence of dental fear and phobia relative to other fear and phobia subtypes. Eur J Oral Sci. 2009 Apr; 117(2):135-143.

18 Kent G. Memory of dental pain. Pain. 1985;21:187–194.

19 Humphris GM, King K. The prevalence of dental anxiety across previous distressing experiences. J Anxiety Disord. 2011;25:232–236.

20 Oosterink FMD, De Jongh A, Hoogstraten J, et al. The Level of Exposure-Dental Experiences Questionnaire (LOE-DEQ): a measure of severity of exposure to distressing dental events. Eur J Oral Sci. 2008;116:353–361.

21 Leeners B, Stiller R, Block E, et al. Consequences of childhood sexual abuse experiences on dental care. J Psychosom Res. 2007;62:581–588. 

22 Uziel N, Bronner G, Elran E, et al. Sexual correlates of gagging and dental anxiety. Community Dent Health. 2012;29:243–247.

23 Eli I, Uziel N, Baht R, et al. Antecedents of dental anxiety: learned responses versus personality traits. Community Dent Oral Epidemiol. 1997;25:233–237.

24 Themessl-Huber M, Freeman R, Humphris G, et al. Empirical evidence of the relationship between parental and child dental fear: a structured review and meta-analysis. Int J Paediatr Dent. 2010;20:83–101.

25 Lara A, Crego A, Romero-Maroto M. Emotional contagion of dental fear to children: the fathers' mediating role in parental transfer of fear. Int J Paediatr Dent. 2012;22:324–330.

26 Locker D, Liddell A, Dempster L, et al. (1999)

27 Öst L. Age of onset of different phobias. J Abnorm Psychol. 1987;96:223–229.

28 Berggren U. Dental fear and avoidance: a study of etiology, consequences and treatment. Göteborg: Göteborg University; 1984.

29 Moore R, Brødsgaard I, Rosenberg N. The contribution of embarrassment to phobic dental anxiety: a qualitative research study. BMC Psychiatry. 2004;4:10–20.

30 Oosterink FM, de Jongh A, Hoogstaten J. (2009)

31 Lin KC. Behavior-associated self-report items in patient charts as predictors of dental appointment avoidance. J Dent Educ. 2009 Feb;73(2):218-224.

32 Armfield JM. What goes around comes around: revisiting the hypothesized vicious cycle of dental fear and avoidance. Community Dent Oral Epidemiol. 2013 Jun;41(3):279-287.

33 Armfield JM. What goes around comes around: revisiting the hypothesized vicious cycle of dental fear and avoidance. Community Dent Oral Epidemiol. 2013;41:279–287.

34 Appukuttan (2016)

35 Marci CD, Ham J, Moran E, Orr SP. Physiologic correlates of perceived therapist empathy and social-emotional process during psychotherapy. J Nerv Ment Dis. 2007;195(2):103–111.

36 Botto RW. Chairside techniques for reducing dental fear. In: Mostofsky DI, Forgione AG, Giddon DB, editors. Behavioral Dentistry. Oxford: Blackwell; 2006. pp. 115–125. 

37 Appukuttan (2016)

38 Ibid.

39 Bare LC, Dundes L. Strategies for combating dental anxiety. J Dent Educ. 2004;68(11):1172–1177.

40 McCaffrey R, Thomas DJ, Kinelman AO. The effects of lavender and rosemary essential oils on test-taking anxiety among graduate nursing students. Holist Nurs Pract. 2009;23(2):88–93.

41 Chen YJ, Shih Y, Chang TM, Wang MF, Lan SS, Cheng FC. In: Spink AJ, Ballintijn MR, Bogers ND, et al., editors. Inhalation of neroli essential oil and its anxiolytic effects in animals; Proceedings of Measuring Behavior 2008: 6th International Conference on Methods and Techniques in Behavioral Research; Wageningen, the Netherlands: Noldus Information Technology; 2008. pp. 256–257.

42 Muzzarelli L, Force M, Sebold M. Aromatherapy and reducing preprocedural anxiety: a controlled prospective study. Gastroenterol Nurs. 2006;29(6):466–471.

43 American Psychological Association. (n.d.) Too much coffee? (accessed 9-17-2022) https://www.apa.org/gradpsych/2015/11/coffee

44 Appukuttan (2016)

45 Ibid.

46 Gonzales EA, Ledesma RJ, McAllister DJ, Perry SM, Dyer CA, Maye JP. Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study. AANA J. 2010;78(3):181–188. 

47 Hirschman R. Physiological feedback and stress reduction; Poster presented at: Annual Meeting of Society of Behavioral Medicine; November 1980; New York.

48 White JM. State of the science of music interventions: critical care and perioperative practice. Crit Care Nurs Clin North Am. 2000;12(2):219–225.

49 Moola S, Pearson A, Hagger C. Effectiveness of music interventions on dental anxiety in paediatric and adult patients: a systematic review. JBI Database System Rev Implement Rep. 2011;9(18):588–630.

50 Cleveland Clinic

51 Shapiro M, Melmed RN, Sgan-Cohen HD, Eli I, Parush S. Behavioural and physiological effect of dental environment sensory adaptation on children’s dental anxiety. Eur J Oral Sci. 2007;115(6):479–483.

52 Cermak SA, Stein Duker LI, Williams ME, et al. Feasibility of a sensory-adapted dental environment for children with autism. Am J Occup Ther. 2015;69(3):1–10. 

53 Shapiro M, Melmed RN, Sgan-Cohen HD, Parush S. (2009)

Narrative Therapy: Integrating Humanistic Storytelling Into Mental Healthcare

Storytelling in Medicine

Our lives are composed of stories. From the timeline of when we are born to when we age, we tell stories of our childhood traumas, our failed relationships, our struggles at work. As human beings, we are "built to absorb, interpret, and respond to stories."[1] Storytelling is thus an intrinsically human capacity, and its conscious integration into mental healthcare is imperative in developing humanistic relationships with patients. 

Narrative medicine, a perspective on medicine that has gained increasing traction in the twenty-first century, focuses on this power of narrative in humanistic care. Founder of narrative medicine, Dr. Rita Charon (2001), discusses narrative as inherent in the patient-physician relationship; during a visit, the patient tells a "story of illness" in "words, gestures, physical findings, and silences," while their patient history comprises a more longitudinal form of story that gives meaningfulness and context to life and illness.[2,3] Like in the narratives we read, understanding a patient happens through not only objective observation and information but also through the fears, hopes, and implications of their life story.[4] Using words and storyline to encompass a patient's worries gives shape and control to the "chaos of illness," helping patients to judge the narrative of their condition in light of its narrative situation.[5] By doing so, storytelling in medicine reinforces autonomy and dignity: "Once the patient's biography becomes part of the care, the possibility that therapy will dehumanize the patient, stripping him of what is unique to his illness experience, becomes much less likely."[6] 

The rise of narrative medicine represents a movement to supplement objective evidence-based psychiatry with a more humanistic and holistic approach. Despite the past century's gradual phase-out of psychoanalysis and anecdotal (story-based) evidence, with father of psychoanalysis Sigmund Freud noting a concern that case histories lacked "the serious stamp of science," Roberts (2000) finds several shortcomings with a solely evidence-based model of psychiatry. Evidence-based medicine prefers the general over the specific, the objective over the subjective, and the quantitative over the qualitative, lacking a metric for existential qualities like inner hurt, despair, hope, grief, and moral pain which "frequently accompany and often constitute" illness.[7] Without narrative, medicine can overlook the patient's humanity and experience of illness. Narrative medicine, on the other hand, adds individuality, distinctiveness, and context to the solid foundation offered by quantitative methods, rounding out evidence-based medicine to give a fuller picture of a patient.[8] 

In this way, narrative medicine can "bridge the divides that separate physicians from patients, themselves, colleagues, and society."[9] Embracing the biopsychosocial model and patient-centered medicine, narrative medicine provides a framework to view clinical work with consequences and meanings, understanding how a situation unfolds over time.[10] As Roberts (2000) discusses, Charon (2001) also writes that scientific competence alone is not enough for a patient to grapple with loss of health or find meaning in suffering; in addition to their more objective training, physicians sometimes "lack the capacities to extend empathy toward those who suffer, and to join honestly and courageously with patients in their illnesses." If we do not emphasize narrative in relationships with patients, patients may not tell their whole story, ask the most frightening questions, or feel heard.[11] Their diagnostic might be unfocused, lacking, more expensive, shallow, or ineffective. As narrative medicine gains traction, patients have begun endorsing the benefits they reap from its practice: "more and more patients have insisted on achieving a narrative mastery over the events of illness, not only to unburden themselves of painful thoughts and feelings but, more fundamentally, to claim such events as parts, however unwelcome, of their lives."[12] 

Theories of Narrative Therapy

The advent of narrative medicine provides a backdrop to the establishment of narrative therapy by White and Epston (1990), a form of therapy based on the theory that people live according to multiple stories and that identity is text which can be understood in innumerable ways.[13,14] Narrative therapy helps patients to create meaning in their own lives: its premise lies in the belief that the stories patients tell of their lives reflect how they internalize and perceive their past and present. Thus, social workers and therapists can help them to understand their reality in different, more empowering, ways.[15,16] Tadros et al. (2022) concurs, describing narrative therapy's goals as bolstering resilience and empowerment through deconstructing and reauthoring personal stories as well as giving voice to unheard individuals. Narrative therapy accordingly lends meaning, autonomy, and control to an individual's understanding of their own life story.

Narrative therapy can be further understood in the context of a few key theories and movements. Roberts (2000) discusses the idea of individual constructivism, where an individual gives meaning to events and creates a story to contain and explain their personal experiences. Tadros et al. (2022) expand this to include social constructionism, in which a group or culture socially constructs perspectives through its interactions and negotiates meaning in community to form a larger narrative. Because these cultural and social discourses can serve to alienate, objectify, or even dehumanize some people, narrative therapy works to discover alternate understandings of self that patients can be comfortable with amidst their culturally-created reality.[17,18] For instance, because cultural values and traditions often express ways in which an individual should and must live, these one-sided values can invalidate individuals who experience the world in divergent ways.[19] Narrative therapy then helps the individual to build distance from cultural discourse and hold more autonomy over their story. 

Stahnke & Cooley (2022) contextualize this with the similar tenets of postmodernism, which considers reality as socially constructed and influenced by language. Postmodernism posits that there is no absolute truth, and that different versions of reality exist through the different labels or perspectives we lend to it, helping to cope with the ambiguities inherent in life.[20] Postmodernism thus does away with the concept of one objective truth waiting to be measured, and instead characterizes the truth as something provisional, ever-changing, dependent on context, and shaped by many forces.[21] To emphasize the importance of bringing subjectivity into the measurable truths of psychiatry, Roberts (2000) provides an example of a young man with schizophrenia, who participated in research interviews over the course of ten years. When asked afterwards which of the ten was the worst year of his life, he identified a year where the objective ratings collected by researchers were in fact favorable. However, it was also the year he had been traumatically rejected by his family and was abandoned, despite his schizophrenia being relatively stable at the time. Such demonstrates how the "individually meaningful" might not always be the same as the "reproducibly measurable," and how personal story should be used to flesh out the understanding of individual experience to avoid missing meaningful aspects of a person's life in therapy.[22] In this way, narrative therapy helps to supplement objective measures with personal experience and better understand the alternate understandings of reality present in different individuals.  

Roberts (2000) additionally discusses psychotherapy in the context of attachment theory, a theory of emotional relationships where individuals develop secure or insecure attachments to other people depending on the stability of their relationship during its formation. During a therapeutic encounter, a patient enters with a story that is often hesitant, unsure, or disjointed; the therapist then helps to uncover a more coherent and satisfying narrative.[23] Roberts links the coherence of one's story to attachment, positing that "how we tell our stories speaks to our stance towards the world." Coherence in storytelling is, then, indicative of a secure attachment, while an insecure attachment could yield an over-elaborated, confused, or sparsely dismissive narrative.[24] In working with insecure attachment in narrative therapy, therapists help patients to find the shape and pattern of a narrative within the "chaos of experience," encouraging the patient to break down their narrative into a manageable and understandable history indicative of a now secure attachment.[25] 

Narrative Therapy in Practice

In narrative therapy, the role of the therapist is to listen, get to know the client, and provide validation and acceptance as they navigate sources of strength and create meaning in the client's life.[26] Tadros et al. (2022) add that narrative therapists encourage and even challenge clients to reauthor more fitting narratives for their lives, providing space for reflection with an emphasis on compassionate connection and emotional attunement. In doing so, they must use carefully chosen language to describe and reframe the individual's experience so that they can express positive and preferred identities and values.[27] The therapist should also reinforce agency and communion at every step of narrative therapy, connecting clients' problems with their relationships and support networks, and panning to a broader picture of the client's past and present experiences of agency and communion.[28] 

To understand how narrative therapy works in practice, Tadros et al. (2022) and Stahnke & Cooley (2022) break down narrative therapy into three main components:

• Deconstruction 

• Externalization

• Reauthoring

Deconstruction involves breaking down the language of a problem, event, or experience to find other possible meanings and understandings.[29] For example, a person could be understood as not just a mentally unwell person, but someone who has yet to work on learning to healthily express their emotions. Deconstruction also involves repurposing statements to frame the individual's feelings and reactions, rather than blaming others for these, using "I am feeling" as opposed to "they make me feel" statements.[30] 

Externalizing focuses on viewing each client as an "individual with a problem, not a problem themselves," separating the human from the condition.[31] Reframing problems as outside of the individual rather than part of the individual, such as labeling it "the depression" instead of "my depression," can help a client regain feelings of autonomy outside of their problems.[32] In this process, therapists can explore how the problem serves a purpose in the client's life rather than constitutes their entire life: for example, the problem could be a concrete thing to project anxiety onto rather than confront unresolved issues, or it could serve as a mechanism for survival.[33] 

Finally, reauthoring involves shifting the client's focus from their problems onto their own strength and resilience, reframing their trauma and lifelong battles to acknowledge their ability to overcome the uncertainty of the future.[34] Often, goals of reauthoring processes include envisioning oneself as a person who can cope instead of fixating on problems, envisioning breaking cycles of trauma imposed during childhood, developing one's own voice as a member of society rather than a burden, and identifying one's ability to make decisions for oneself and regulate emotions. In reauthoring their story, clients can take back control that had been given to their problems and survival mechanisms.

Several narrative techniques can be implemented to facilitate narrative therapy. Koganei et al. (2021) suggest developing a "landscape of consciousness and of action," in which clients make a list of beliefs that rob the power of their dreams and goals from them, in order to then reclaim that power and write stories they are satisfied with. Koganei et al. also suggest narrative tasks involving remembering and imagining one's legacy as a longitudinal contribution to a larger community story, giving additional meaning and worth to oneself through imagining impact on others. Charon (2001) speaks more broadly of elements of story that can be helpful creative resources in narrative therapy, such as paying attention to associations, allusions to other stories, and using metaphor to convey digestible meanings to a client. 

Tadros et al. (2022) elaborates on the importance of metaphors to convey difficult feelings and trauma, suggesting the use of poems to reflect and unpack words, images, phrases, and metaphors. Metaphor "softens the dive into meaning," working with a client's understanding without threatening the defenses of someone who may not be ready to hear unbearable meanings of their experiences.[35] Especially with those from diverse cultures and backgrounds, using traditional stories in therapy as metaphor for their experiences can help contextualize their problems within an accessible narrative of traditional hubs of wisdom.[36] A particular example of this is the usage of the Tree of Life in therapy, a method originally developed to treat trauma in African youth.[37] In the process, participants can draw trees and reflect on the major elements of their lives such as their past, resources, and strengths, through the metaphors of roots, nutrients, growth, and branches, to facilitate their integration of their experiences in life. 

Benefits and Applications of Narrative Therapy

Studies have identified efficacy and many benefits to the usage of narrative therapy. In a Japanese study of seven narrative therapy patients by Koganei et al. (2021), participants reported experiencing insight, beginning to solve problems, finding a new understanding of self, clarification of problems, and clarification of thoughts about societal problems after narrative therapy. Patients additionally felt more "forward-looking" and higher amounts of motivation, desiring to make concrete changes in their life. When scored with the Beck Depression Inventory (Second Edition), four of seven participants had declines in scores for past failure, self-criticization, and worthlessness, while three had declines in scores for self-dislike, changes in sleeping patterns, and irritability. One participant's severity of depression additionally changed from severe to minimal between initial and final meetings, while three had lower scores during the final meeting despite not reaching the threshold for minimal depression.[38] Tadros et al. (2022) additionally found narrative therapy helpful in treating certain groups: narrative therapy was statistically efficacious in treating borderline personality disorder and in reducing anxiety and panic symptoms for a woman with somatic symptom disorder. Tadros et al. also notes that group narrative therapy helped to lessen symptoms of social phobia in patients by creating a safe and non-threatening culture of story-making. 

Williams-Reade et al. (2014) provide an extension of narrative therapy for refugees with post-traumatic stress disorder (PTSD), where narrative therapy was able to provide validation, connection, and support as well as help the individuals to view themselves apart from their illness. Stahnke & Cooley (2022) additionally study the efficacy of narrative therapy in end-of-life care, where telling one's story in one's final days can help make meaning out of a person's past and unknown future. By examining how painful experiences have shaped a person's life and discussing their contributions to the world, patients can feel greater integrity for their life history. When patients near death are encouraged to "rewrite" experiences that hold them back and give them regret, they are able to grieve, accept, and embrace their unchangeable reality, finding greater peace. Such leaves patients more prepared to face death, having left behind the legacy of their life narrative.[39]

More broadly, Roberts (2000) found that patients who had undergone narrative therapy were able to give more cognitive and emotional significance to their experiences, construct and negotiate a social identity, and give moral and existential weight to their actions. Therapists were also able to cultivate more empathy and deeper understanding of patients' experience with mental health through their specific personal stories: Roberts (2000) cites a case where a man described his depression as worse than watching his wife die from cancer, a story which gave weight to the desensitizing statistics and objective measurements often thrown around about depression. 

Limitations of Narrative Therapy

Some limitations to narrative therapy remain, and more research should be undertaken to fully understand its benefits and effects. Stahnke & Cooley (2022) note the lack of a solid research base and assessment tools for them to understand the efficacy of its use in their practice. Although narrative therapy techniques are commonly employed by social workers and therapists, they are much less often discussed or documented as a formal therapy, giving less concrete information to work with.[40] Koganei et al. (2021) also raise caution because some participants in narrative therapy did experience anxiety and distress from their sessions, perhaps due to the stress of sharing vulnerable parts of themselves and facing heavy life problems. Increased emotional support alongside narrative therapy may be a necessary intervention to prevent adverse reactions to this intense vulnerability. 

Roberts (2000) also cautions against potential misuse of narrative theories and techniques, stressing the difference between narrativization and novelization. In narrative therapy, it is incredibly important not to sensationalize a patient's story; one must be careful in word choice and metaphor to ensure they are not skewing the truth.[41] On the other hand, too much clarity or simplicity could also deny appropriate complexity, and therapists must be careful not to be insistent on one particular understanding of the truth. Attributing sufferings to particular experiences has the potential to create "shackling narratives which foreclose the future and condemn the past," which can even contribute to cultures of victimization of patients.[42] Remaining open and attentive to nuance in narrative therapy is imperative to prevent this. 

Ultimately, narrative therapy allows patients and therapists to realign themselves with new, more empowering definitions and goals of recovery.[43] In adjusting to living more comfortably with the reality of one's past and present, patients can work towards goals of restoring hope, agency, and self-determination that feel both realistic and inspirational. As the narrative medicine movement continues to gain traction, incorporating narrative context and storytelling into therapy will serve as an important model on the path towards empowering and humanistic care.  

Contributed by: Anna Kiesewetter

Editors: Jennifer (Ghahari) Smith, Ph.D. & Brittany Canfield, Psy.D.

References

1 Charon, R. (2001), Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA, 286 (15): 1897-1902. https://jamanetwork.com/journals/jama/fullarticle/194300 

2 Ibid.

3 Roberts, G.A. (2000), Narrative and severe mental illness: what place do stories have in an evidence-based world? Advances in Psychiatric Treatment, 6: 432-441. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/AC4112C21F3E985C3174AA362D009D45/S1355514600009263a.pdf/narrative-and-severe-mental-illness-what-place-do-stories-have-in-an-evidence-based-world.pdf 

4 Charon (2001)

5 Ibid. 

6 Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York, NY: Basic Books; 1988. 

7 Roberts (2000)

8 Ibid.

9 Charon (2001)

10 Ibid. 

11 Ibid. 

12 Ibid.

13 White, M., & Epston, D. (1990) Narrative means to therapeutic ends. W. W. Norton & Company.

14 Koganei, K., Asaoka, Y., Nishimatsu, Y., Kito, S. (2021), Women's Psychological Experiences in a Narrative Therapy-Based Group: An Analysis of Participants' Writings and Beck Depression Inventory–Second Edition. Japanese Psychological Research, 63 (4): 466-475. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jpr.12326. 

15 Stahnke, B., Cooley, M.E. (2022), End-of-Life Case Study: The Use of Narrative Therapy on a Holocaust Survivor with Lifelong Depression. Journal of Contemporary Psychotherapy, 52: 191-198. https://doi.org/10.1007/s10879-022-09532-z

16 Tadros, E., Cappetto, M., Aguirre, N. (2022), Treating specific phobia fear of injury through narrative therapy post-release: A clinical case study. The Journal of Forensic Psychiatry & Psychology, 33 (3): 445-460. https://www.tandfonline.com/doi/epub/10.1080/14789949.2022.2065332?needAccess=true. 

17 Koganei et al. (2021)

18 Williams-Reade, J., Freitas, C., Lawson, L. (2014), Narrative-Informed Medical Family Therapy: Using Narrative Therapy Practices in Brief Medical Encounters. Families, Systems, & Health, 32 (4): 416-425. https://psycnet.apa.org/fulltext/2014-44118-001.pdf?auth_token=c50f991971df27650e05ae8e91f5b1109a193e41. 

19 Koganei et al. (2021)

20 Stahnke & Cooley (2022)

21 Roberts (2000)

22 Ibid.

23 Ibid. 

24 Ibid.

25 Ibid. 

26 Stahnke & Cooley (2022)

27 Tadros et al. (2022)

28 Williams-Reade et al. (2014)

29 Tadros et al. (2022)

30 Stahnke & Cooley (2022)

31 Tadros et al. (2022)

32 Stahnke & Cooley (2022)

33 Tadros et al. (2022)

34 Stahnke & Cooley (2022)

35 Roberts (2000)

36 Ibid.

37 Koganei et al. (2021)

38 Ibid.

39 Stahnke & Cooley (2022)

40 Ibid.

41 Roberts (2000)

42 Ibid.

43 Ibid.

Teachers in Crisis: Understanding Mental Health through Maslow's Hierarchy of Needs

A Five-Alarm Crisis

Nationwide, an estimated 389,300 teachers left the profession between February 2020 and January 2022,[1] and data indicates the exodus is not over. A survey this year, conducted by the National Education Association (NEA), found that approximately 55% of teachers are considering resigning or retiring ahead of schedule.[2] These predictions have become so severe that NEA’s president, Becky Pringle, has described the current situation as, “a five-alarm crisis.”[3]

As the Nevada Public School system prepares to open its doors for the new school year, it has 3,000 vacancies including teachers, bus drivers, and cafeteria workers.[4] Yet Nevada is not the only state facing this shortage. Chuck North, the Superintendent of Reading Community Schools in Michigan, describes that school districts within his state are now stealing teachers from each other because there are no new candidates out there.[5] Schools are scrambling to fill vacancies by relaxing teacher certification requirements, [6-8] and many are left wondering what went wrong.

Returning to Maslow

Mental health in schools is usually discussed in terms of addressing the needs of students, but in light of the current crisis, it has become apparent that it is time to expand this discussion to address the well-being of school employees.[9] A RAND study from 2021, shows that since the pandemic began, teachers were “almost three times more likely to report symptoms of depression than other adults,” resulting in a mental health crisis that is taking thousands of teachers out of their professions.[10]

In 1943, psychologist Abraham Maslow published his hierarchy of needs, listing five levels of needs/requirements that must be met in order for human beings to thrive.[11] This hierarchy is organized in the shape of a pyramid (see below) with the most essential human needs for survival on the bottom, working up to the ideals of a fulfilled life.[12] The theory states that the lower levels of the pyramid must be met one layer at a time before progressing to the next level.[13] Maslow’s hierarchy has been used in teacher training programs for decades, but it is usually focused on how meeting student needs can facilitate learning.[14] In light of the current staff shortage, it may be time to revisit the pyramid and consider its application to the needs of educators.

Image source from Simply Psychology[15]

Level 1: Physiological Needs

The bottom of the pyramid describes the physiological needs that are essential for human survival.[16] These includes items such as food, water, air, shelter, and sleep;[17] it is believed that these needs must be met before moving on to fulfilling ideal desires.[18] When educators analyze this level in terms of student success, one consideration is whether children have “food security” at home, yet the discussion of whether teachers experience food insecurity is often not considered.

Food Security: Food security has been defined as, “having dependable access to enough food for active, healthy living.”[19] In the Spring of 2020, researchers studying the link between depression and food insecurity in a cohort of low-income families and educators in the Tulsa, Oklahoma metro area, found that before the pandemic began, 24% of teachers surveyed were considered food-insecure.[20] While this number dropped slightly during the pandemic, possibly due to programs like grab-and-go bagged lunches distributed at schools, it did not drop below 20%.[21] A separate survey of 862 elementary school teachers who serve low-income communities within the US also found that 29.1% reported experiencing food insecurity.[22] This prevalence of food insecurity in educators is likely linked to the low pay received in many school districts, which falls under “safety needs,” and brings us to the next section of the pyramid.

Level 2: Safety Needs

The second level of Maslow’s hierarchy addresses safety needs, which includes sufficient income/employment, maintenance of health, and personal safety.[23] Though the majority of teachers have the resources available to meet their basic physiological needs, this is the level where many begin to struggle.

Sufficient Income: In 2018, it was determined that teachers made 21.4% less than their non-teaching counterparts when adjusting for experience and education.[24] As an example, the Michigan Educators Association states that a new teacher in Michigan makes an average of $37,320 per year.[25] Similarly, an anonymous elementary school teacher from Richmond, Virginia told Newsweek that he is working 60 hours per week, but still struggles to support his family since a continually increasing workload prevents him from getting a second job.[26] Low salaries result in creating a state of continual stress and anxiety. This problem has been an ongoing issue, as illustrated by the fact that during the 2015-2016 school year, 59% of teachers reported picking up additional work outside of the school day.[27]

Maintenance of Health: Health has become increasingly difficult to maintain during the COVID-19 pandemic. When early childhood educators were deemed essential workers, they struggled with their own fears of safety amidst the spread of contracting the contagious illness.[28] The CDC guidelines for addressing COVID-19 made teachers feel that they had to choose between their health and their profession, causing some to feel the risk was not worth it.[29] Phylicia Jiminez, a former English teacher, told Newsweek that she had gotten used to lockdown drills and other threats, but that being asked to return to the classroom during the pandemic without protection made her feel that, “they’re actually trying to kill us… there’s no desire to help us out in any way.”[30] When teachers returned to the classroom after lockdowns, they struggled to find the balance between keeping students engaged while implementing social distancing and mask wearing for safety.[31]

Since returning to the classroom, teachers have continued struggling with their physical health. In the past year, they have reported experiencing: weight loss; digestive issues; anxiety attacks; racing heartbeat and headaches.[32] Further, stress in educators and other school employees has been connected to increased illness, fatigue, and absenteeism.[33] A middle school teacher from Los Angeles, Bethany Collins, describes having used all of her sick days for maternity leave and then being told that if she or a family member contracted COVID-19 she would not be able to take any paid time off.[34] After the peak of the COVID-19 pandemic, students fell academically behind, but instead of lessening testing requirements, Rahman (2022) found that teachers believe they are being asked to test even more, increasing the pressure of the job.[35]

Personal Safety:  The Uvalde school shooting on May 29th, resulted in the death of 19 students and 2 teachers,[36] reminding school staff once again of the increasing dangers of their profession. Since the Sandy Hook tragedy, 900 school shootings have taken place,[37] and as of July, 83 people have been killed or injured in 2022 from gun violence in schools.[38] This leaves teachers having to reassure students and parents of safety when they are often processing the traumatic events, themselves. Teachers and school staff members have experienced negative mental health effects from school shootings including sleep disorders, appetite loss, increased fatigue, decreased appetite, and heightened startle reflex.[39] Simply hearing about these events can cause teachers to imagine themselves in that scenario and lead to vicarious trauma.[40]

Yet school shootings are also not the only threats to educator safety. A recent survey conducted by the American Psychological Association estimated that one third of teachers reported experiencing threats or verbal harassment from a student since the beginning of the pandemic, and over 40% of administrators reported at least one threatening incident from a parent during COVID.[41] Dr. Susan Dvorak McMahon, chair of the APA Task Force on Violence Against Educators and School Personnel, states that, “Violence against educators is a public health problem.”[42] Safety has been a growing concern for several years as an analysis conducted in 2019 showed that 12.4% of teachers reported being physically attacked by a student at their school and 21.8% had been threatened at work.[43] Maslow’s theory suggests that educators will not be able to move to focusing on higher levels of fulfillment until this basic need for safety is met.[44]

Level 3: Love and belonging

Maslow’s third level focuses on feeling loved and having a sense of belonging. This includes maintaining friendships, experiencing intimacy, close family ties, and having a sense of connection.[45]

Connection and Belonging: An analysis of teacher’s own perception of their occupation, published in March of 2020,noted educators felt they did not have relationships that were nurturing with administrators or colleagues.[46] When the pandemic began, there was a brief surge in respect for teachers, with even celebrities sharing praise for the profession.[47] Yet the surge of glory was short lived, and the past year has thrown educators into the depths of highly-charged battles, such as teaching critical race theory,[48] and protests over mask mandates[49-51]. Clay Michalec, a band teacher with over ten years of experience from Maryland, shared the added stress of a parent threatening to report him to a senator, over displaying Black Lives Matter and LGBTQ pride flags, had such an impact on his mental health that he wasn’t able to come off of antidepressants, or even feeling human again, until he changed careers.[52] Even in 2020, at the beginning of the pandemic, public school K-12 teachers as well as childcare providers reported a spike in symptoms of depression.[53]

Educators are also susceptible to a phenomenon known as secondary traumatic stress, or compassion fatigue, which is developed from knowing about another person’s traumatic experiences and the stress that develops from wanting to help the person who is suffering. [54] As a result, teachers who are trying to help a student deal with abuse or distress at home can have their own mental and physical health impacted.[55] The burnout and exhaustion related to teaching can result in emotional numbing, feeling “shut down,” increased pessimism, problems with boundaries, and a lack of enjoyment.[56]

Level 4: Esteem

Maslow’s fourth level of the pyramid addresses an individual’s need to feel respect, self-esteem, status, recognition, strength, and freedom.[57]

Respect: A recent article in NEA news stated, “The root cause of educator exhaustion and frustration is a lack of support and respect.”[58] The perceived lack of respect for those in the education system is illustrated by NEA President Pringle explaining that some politicians have been attacking schools and trying to divide parents from educators instead of working with teachers to find solutions.[59] The criticism of educators over the past two years has left them feeling disrespected. Wendy Grider, a four-grade teacher who recently resigned, describes seeing parents in her district criticizing homework assignments over social media this year while inside classrooms teachers were dealing with disrespect and threats from students.[60]

Freedom: The changes to the education system have also taken away the autonomy of teachers to make decisions about the curriculum and create an environment in their classrooms that is supportive to their students.[61] Educators report having little input into new policies enacted in their own schools and do not feel consulted as professionals.[62] In fact, Garcia & Weiss (2020) found that over 70% of teachers indicated that they do not have input as to the materials they use within their classes or what content they teach.[63] This feeling was only amplified last school year when Oklahoma proposed fining teachers $10,000 if they taught controversial topics perceived to be against a student’s religion, including birth control or the Big Bang Theory.[64] It was then further heightened by proposed legislation in various states aimed at installing live camera feeds in classrooms,[65-67] which educator advocates believe is an attempt at censoring teachers and, in an Iowa proposal, a 5% fine of a teacher’s weekly salary would be enacted if their camera became disabled.[68] This is in addition to another perceived assault on teacher freedom from Florida’s “Don’t Say Gay” law which educators worry would regulate the way they can support LGBTQ students and families.[69] One-by-one, the freedom of teachers to make decisions about how and what they teach is being stripped away, which can impact the needed sense of freedom and autonomy to teach the core content of their curriculum in an effective way.

Level 5: Self-actualization

The Goal: The final level of Maslow’s hierarchy of needs occurs when an individual reaches the highest levels of self-actualization.[70] At this stage, a person feels they are living their best lives to the fullest extent possible.[71] They are able to be creative and feel fulfilled in their careers.[72] However, according to Maslow, it is not possible to attain this stage unless prior needs are met. Maslow’s theory of motivation teaches us that as long as teachers are pulled down by obstacles in the lower levels of the pyramid, they will be hindered from achieving this ideal goal.[73]

Examples of burnout exist across the country. Scott Henderson, a ninth grade social studies teacher who left half-way through last school year, explains that when he had to go to the classroom door to speak with a parent who arrived unannounced, he turned back into the room to find students throwing tampons at the ceiling and rummaging through his desk.[74] Similarly, Kaitlin Moore, a former teacher, describes the emotional blackmail that is experienced in schools when teachers are told that, “since everything is for the kids,” not wanting to do something when you’re instructed to must mean that you “don’t love the kids enough.”[75] Another teacher shared the irony of  being told to practice self-care by administration while simultaneously being denied the right to use personal leave.[76]

These examples illustrate that as long as educators are placed in the position of battling for lower-level needs, it will be difficult for them to ever achieve the highest level of self-actualization that can enable them to thrive successfully in their careers. Studies have shown that teacher’s mental health impacts not only the mental health of the students, but also the overall effectiveness of the learning environment.[77] Expanding the influence of Maslow’s hierarchy to not only dictate student needs, but educator needs as well, would help to ensure the needs of all those involved are met.

 Contributed by: Theresa Nair

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

REFERENCES

1 Walker, T. Beyond burnout: What must be done to tackle the educator shortage | NEA. https://www.nea.org/advocating-for-change/new-from-nea/beyond-burnout-what-must-be-done-tackle-educator-shortage. Updated 2022a. Accessed Jul 27, 2022.

2 Rahman, K. America's teacher exodus leaves education system in crisis. Newsweek Web site. https://www.newsweek.com/americas-teacher-exodus-education-system-crisis-1679415. Updated 2022. Accessed July 28, 2022.

3 Will, M. Will There Really Be a Mass Exodus of Teachers? Experts see poor morale as a warning sign, but are wary about making predictions about turnover. Education week. 2022;41(25):4-.

4 News ABC. Nevada official laments teacher, staff shortages ahead of back-to-school season. ABC News Web site. https://abcnews.go.com/US/nevada-official-laments-teacher-staff-shortages-ahead-back/story?id=87926108. Updated 2022. Accessed Aug 13, 2022.

5 Mauriello, T. Chalkbeat: Michigan Has a Teacher Shortage Problem. Newstex; 2022.

6 Powell Crain, T. Alabama lowers teacher certification requirements, effective immediately. al Web site. https://www.al.com/educationlab/2022/07/alabama-approves-immediate-changes-to-teacher-certification-praxis.html. Updated 2022. Accessed Aug 13, 2022.

7 Military veterans teacher certification pathway now open. The School District of Lee County Web site. https://www.leeschools.net/news/august_2022/veterans_teacher_certification_pathway. Updated 2022. Accessed Aug 13, 2022.

8 Will, M. States relax teacher certification rules to combat shortages. Education Week. June 28, 2022. Available from: https://www.edweek.org/teaching-learning/states-relax-teacher-certification-rules-to-combat-shortages/2022/06. Accessed Aug 13, 2022.

9 Lever, N., Mathis, E., Mayworm, A. School Mental Health Is Not Just for Students: Why Teacher and School Staff Wellness Matters. Rep Emot Behav Disord Youth. 2017;17(1):6-12.

10 Noonoo, S. The mental health crisis causing teachers to quit. Ed Surge Web site. https://www.edsurge.com/news/2022-05-02-the-mental-health-crisis-causing-teachers-to-quit. Updated 2022. Accessed July 29, 2022.

11 Gepp, K. Maslow’s hierarchy of needs pyramid: Uses and criticism. https://www.medicalnewstoday.com/articles/maslows-hierarchy-of-needs. Updated 2022. Accessed Aug 13, 2022.

12 Mcleod, S. [Maslow's hierarchy of needs]. Simply Psychology Web site. https://www.simplypsychology.org/maslow.html. Updated 2022. Accessed Aug 13, 2022.

13 Gepp (2022)

14 Panka, L. Maslow’s hierarchy of needs in schools. . 2022. https://csaedu.com/maslows-hierarchy-of-needs-in-schools/. Accessed Aug 13, 2022.

15 Mcleod (2022)

16 Gepp (2022)

17 Ibid.

18 Maslow, AH. A theory of human motivation. Psychological review. 1943;50(4):370-396. doi:10.1037/h0054346

19 Coleman-Jensen A, Gregory C, Singh A. Household Food Security in the United States in 2013.; 2014.

20 Martin, A., Partika, A., Castle, S., Horm, D., Johnson, AD. Both sides of the screen: Predictors of parents’ and teachers’ depression and food insecurity during COVID-19-related distance learning. Early childhood research quarterly. 2022;60:237-249. doi:10.1016/j.ecresq.2022.02.001

21 Ibid.

22 Li, F., Parthasarathy, N., Zhang, F., et al. Food Insecurity and Health-Related Concerns Among Elementary Schoolteachers During the COVID-19 Pandemic. Preventing chronic disease. 2022;19:E27-E27. doi:10.5888/pcd19.210392

23 Gepp (2022)

24 García, E., Weiss, E. How teachers view their own professional status: A SNAPSHOT. Phi Delta Kappan. 2020;101(6):14-18. doi:10.1177/0031721720909581

25 Mauriello (2022)

26 Rahman (2022)

27 Garcia & Weiss (2020)

28 Crawford, A., Vaughn, KA., Guttentag, CL., Varghese, C., Oh, Y., Zucker, TA. “Doing What I can, but I got no Magic Wand:” A Snapshot of Early Childhood Educator Experiences and Efforts to Ensure Quality During the COVID-19 Pandemic. Early childhood education journal. 2021;49(5):829-840. doi:10.1007/s10643-021-01215-z

29 Rahman (2022)

30 Ibid.

31 Crawford et al. (2021)

32 Noonoo (2022)

33 Lever et al. (2017)

34 Noonoo (2022)

35 Rahman (2022)

36 Strickland, M. Idaho capital sun - states newsroom: Parents must be prepared to talk to their kids about school shootings. here are tips on how. Idaho Capital Sun. 2022.

37 Li, Jones & Livingston, Kelly. Teachers face mental health challenges dealing with school shootings. ABC News Web site. https://abcnews.go.com/Politics/teachers-face-mental-health-challenges-school-shootings/story?id=85069493. Updated 2022. Accessed Jul 11, 2022.

38 School shootings this year: How many and where. Education Week. -01-05T18:16:47.67 2022. Available from: https://www.edweek.org/leadership/school-shootings-this-year-how-many-and-where/2022/01. Accessed Jul 11, 2022.

39 Alexander, BA., Harris, H. Public School Preparedness for School Shootings: A Phenomenological Overview of School Staff Perspectives. School mental health. 2020;12(3):595-609. doi:10.1007/s12310-020-09369-8

40 Li & Livinson (2022)

41 Violence against educators and school personnel: Crisis during COVID. American Psychological Association. 2022. https://www.apa.org/education-career/k12/violence-educators.pdf.

42 Walker, T. Violence, threats against teachers, school staff could hasten exodus from profession | NEA. https://www.nea.org/advocating-for-change/new-from-nea/violence-threats-against-teachers-school-staff-could-hasten. Updated 2022b. Accessed Aug 14, 2022.

43 Garcia & Weiss (2020)

44 Maslow (1943)

45 Mcleod (2022)

46 Garcia & Weiss (2020)

47 Noonoo (2022)

48 Ibid.

49 Wang, H., Bellamy, L. Parents protest masks in rallies outside warwick schools. Times Herald-Record. February 16, 2022. Available from: https://www.recordonline.com/story/news/2022/02/16/warwick-rally-against-mask-mandate-schools/6811872001/. Accessed August 14, 2022.

50 Rahman, K. Students walk out of schools across the country over mask mandates. Newsweek Web site. https://www.newsweek.com/students-walk-out-schools-over-mask-mandates-1677954. Updated 2022. Accessed Aug 14, 2022.

51 Shivaram, D. The topic of masks in schools is polarizing some parents to the point of violence. NPR Web site. https://www.npr.org/sections/back-to-school-live-updates/2021/08/20/1028841279/mask-mandates-school-protests-teachers. Updated 2021. Accessed August 14, 2022.

52 Will (2022)

53 Crawford et al. (2021)

54 Lever et al. (2017)

55 Ibid.

56 Ibid.

57 Mcleod (2022)

58 Walker (2022a)

59 Ibid

60 Kathryn, Dill. School’s Out for Summer and Many Teachers Are Calling It Quits; Educators say they are worn down by the Covid-19 pandemic, understaffed schools and political battles. Districts warn of a worsening shortage. The Wall Street journal. Eastern edition. 2022.

61 Walker, T. Educators fight back against gag orders, book bans and intimidation | NEA. NEA | National Education Association Web site. https://www.nea.org/advocating-for-change/new-from-nea/educators-fight-back-against-gag-orders-book-bans-and-intimidation. Updated 2022c. Accessed Aug 15, 2022.

62 Garcia & Weiss (2020)

63 Ibid.

64 Staff, IE. Oklahoma bill could see teachers fined $10K and lose job for teaching anything contradicting religion. Inside Edition Web site. https://www.insideedition.com/oklahoma-bill-could-see-teachers-fined-10k-and-lose-job-for-teaching-anything-contradicting. Updated 2022. Accessed Aug 15, 2022.

65 Whitton, G. Good wants cameras in classrooms. CBS 19 News Web site. http://www.cbs19news.com/story/46976992/bob-good-wants-cameras-in-classrooms. Updated 2022. Accessed Aug 15, 2022.

66 Next, E. Cameras in the classroom. . 2022. https://www.educationnext.org/cameras-in-the-classroom-iowa-florida-lawmakers-introduce-bills/. Accessed Aug 15, 2022.

67 McShane, M. Please don’t put cameras in classrooms. Forbes Web site. https://www.forbes.com/sites/mikemcshane/2022/02/14/please-dont-put-cameras-in-classrooms/. Updated 2022. Accessed Aug 15, 2022.

68 Edelman, A. Iowa bill would require cameras in public school classrooms. NBC News Web site. https://www.nbcnews.com/politics/politics-news/iowa-bill-require-cameras-public-school-classrooms-rcna14789. Updated 2022. Accessed Aug 15, 2022.

69 Cole, D., Burnside, T. DeSantis signs controversial bill restricting certain LGBTQ topics in the classroom. CNN Web site. https://www.cnn.com/2022/03/28/politics/dont-say-gay-bill-desantis-signs/index.html. Updated 2022. Accessed Aug 15, 2022.

70 Maslow (1943)

71 Mcleod (2022)

72 Maslow (1943)

73 Ibid.

74 Dill (2022)

75 Noonoo (2022)

76 Ibid.

77 Gray, C., Wilcox, G., Nordstokke, D. Teacher Mental Health, School Climate, Inclusive Education and Student Learning: A Review. Canadian psychology = Psychologie canadienne. 2017;58(3):203-210. doi:10.1037/cap0000117

Alzheimer’s Disease: Potential Mitigation of Cognitive Decline

Understanding the Path to Progression

Alzheimer’s disease (AD) is the 7th leading cause of death in adults in the United States.[1] The most frequent form of dementia, Alzheimer’s annihilates significant brain processes and memories. Scientists have investigated cognitive decline, an early symptom of this clinical condition, to better understand the disease’s path to progression. Despite copious amounts of research conducted on the subject, definitive cures have yet to be found to prevent the severe symptoms of Alzheimer’s disease and reduce the risk of cognitive decline.[2,3]

Common signs and symptoms of AD include memory loss, challenges in executive functioning skills (e.g., planning or solving problems) and difficulty completing familiar tasks. People with AD experience cognitive decline and are unable to function at their maximum mental capacity. This negative interference in behavioral and social skills affect people’s ability to live independently. In the diagnosis of AD, it is important to rule out potential mental health disorders, as many of the cognitive features of AD (particularly poor thinking ability and memory problems) are notably common symptoms of depression as well.[4] 

Understanding the molecular aspects of Alzheimer’s is key to determining the causes of this disease. Molecular pathways of AD in the brain indicate a loss of blood flow due to certain plaques and show neuronal cell loss, affecting the development of AD.[5] The neurodegenerative properties of Alzheimer’s have shown to be associated with an accumulation of the amyloid-β protein, increased neuronal cell death, and reduced blood flow to the brain.[6] Scientists have attempted to illustrate the pathogenesis of AD with the widely known Amyloid cascade hypothesis, which describes the build-up of the β amyloid production as the cause of neurodegeneration and neuronal cell loss in AD.[7-10] This medical hypothesis illustrates that the deposition of amyloid protein corresponds to neurotoxicity, a critical element in Alzheimer’s disease.[11,12] These neurofibrillary tangles (masses of hyperphosphorylated tau protein in the brain) are a chief marker in detecting Alzheimer’s disease and are caused by the aggregation of amyloid plaques.[13,14] 

The pathology of Alzheimer’s has been positively correlated with deficiencies in or elevated levels of: specific vitamins (particularly vitamin B); dietary folate; and levels of homocysteine.[15-17] Complex data sets by Farina et al. (2017), Mikkelsen et al. (2016), and Robinson et al., (2017), suggest elevated levels of homocysteine, an amino acid in the body, as a marker for Alzheimer’s disease.[18-20] Homocysteine is produced from the methylation cycle (a biochemical pathway involved in most chemical reactions that occur in the body); ineffective methylation reactions can lead to several health disorders, including neurological diseases such as Alzheimer’s.[21] Notably, a lack of vitamin B and folate causes a high level of homocysteine, which is believed to be a risk for cognitive decline.[22,23] Similar to homocysteine, Vitamin D deficiency has been shown to have an influence on AD due to its neurodegenerative accelerating property and causes a disturbance to the vascular system and endothelium.[24] Due to the effect of homocysteine on cognition and its link to contributing factors of AD (e.g., brain atrophy and oxidative stress) scientists are examining whether reducing its levels could restrict the progression of Alzheimer’s disease.[25] 

Dietary modifications may reduce the risk of developing Alzheimer’s disease. De Wilde et al. (2017) and Robinson et al. (2017) have found that this neurological illness is common in the elderly population; as the majority of this cohort has low levels of vitamin B, folate, and vitamin D, supplementation may help ward off neurodegeneration, and ultimately, Alzheimer’s disease.[26,27] Research indicates specific dietary adjustments such as adhering to the Mediterranean diet (which is typically high in vitamin B and antioxidants) are recommended for protection against AD. Consisting primarily of plant-based foods and fish, the Mediterranean diet is low in unsaturated fats; conversely, diets high in fats have been linked to greater risk for AD. Further, de Wilde et al. (2017) have found direct correlations among obesity and diabetes with the development of Alzheimer’s.[28] Thus, current research suggests that changing one’s lifestyle, by supplementation of additional folate and other B vitamins (B6 or B12), may help lessen the probability of getting Alzheimer’s disease later in life. Keep in mind that it is important to consult a physician before adding any vitamins or supplements to ensure the dosage is appropriate for one’s specific needs as well as to safeguard against any adverse interactions with current medications or medical issues.

In addition to dietary adjustments, evidence suggests exercise has specific psychological benefits that pertain to AD. Meng et al. (2020) found that the risk of AD can be significantly lowered by 45%, to be exact, with physical activity.[29] For instance, doing exercise on a regular basis enhances neurogenesis, muscle development, memory improvement, and brain plasticity by improving the endurance of the brain towards oxidative stress and increasing energy metabolism, vascularization, and neurotrophin synthesis.[30] Through these mechanisms, exercise has positive effects on memory and cognitive functions. As for specific types of exercise, strength and resistance training in particular have been found to increase muscle mass which reduces the risk of individuals being diagnosed with AD.[31] Conversely, many studies have demonstrated that a lack of physical activity is one of the most common preventable risk factors for the onset of AD.[32] In addition, compared to medication, exercise has been shown to have fewer side effects and better adherence. 

If you suspect you or someone in your family is exhibiting warning signs or symptoms of Alzheimer’s Disease, it is important to get tested as soon as possible as early detection is key to slowing the progression of this neurodegenerative disease. A qualified mental health professional such as a psychologist or psychiatrist can help rule out whether the symptoms stem from clinical depression or other cognitive-impairing disorders.

Contributed by: Preeti Kota

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

REFERENCES

1 Centers for Disease Control and Prevention. (2022, January 13). FASTSTATS - leading causes of death. Centers for Disease Control and Prevention. Retrieved August 7, 2022, from https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

2 Mikkelsen, K., Stojanovska, L., Tangalakis, K., Bosevski, M., & Apostolopoulos, V. (2016). Cognitive decline: A vitamin B perspective. Maturitas, 93, 108–113. https://doi.org/10.1016/j.maturitas.2016.08.001

3 Mayo Foundation for Medical Education and Research. (2022, February 19). Alzheimer's disease. Mayo Clinic. Retrieved August 7, 2022, from https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/symptoms-causes/syc-20350447

4 Tsuno, N., & Homma, A. (2009). What is the association between depression and alzheimer’s disease? Expert Review of Neurotherapeutics, 9(11), 1667–1676. https://doi.org/10.1586/ern.09.106

5 Robinson, N., Grabowski, P., & Rehman, I. (2018). Alzheimer’s disease pathogenesis: Is there a role for folate? Mechanisms of Aging and Development, 174, 86–94. https://doi.org/10.1016/j.mad.2017.10.001

6 Ibid.

7 Ibid.

8 Roher, A. E., Kokjohn, T. A., Clarke, S. G., Sierks, M. R., Maarouf, C. L., Serrano, G. E., Sabbagh, M. S., & Beach, T. G. (2017). App/AΒ structural diversity and alzheimer's disease pathogenesis. Neurochemistry International, 110, 1–13. https://doi.org/10.1016/j.neuint.2017.08.007

9 Robertson, D. S. (2017). Proposed biochemistry of parkinson’s and alzheimer’s diseases. Medical Hypotheses, 109, 131–138. https://doi.org/10.1016/j.mehy.2017.08.013

10 Shao, W., Peng, D., & Wang, X. (2017). Genetics of alzheimer’s disease: From pathogenesis to clinical usage. Journal of Clinical Neuroscience, 45, 1–8. https://doi.org/10.1016/j.jocn.2017.06.074

11 Roher et al. (2017) 

12 Robertson (2017)

13 Roher et al. (2017) 

14 Ulstein, I., & Bøhmer, T. (2016). Normal vitamin levels and nutritional indices in alzheimer’s disease patients with mild cognitive impairment or dementia with normal body mass indexes. Journal of Alzheimer's Disease, 55(2), 717–725. https://doi.org/10.3233/jad-160393

15 Robinson et al. (2017)

16 Moretti, R., Caruso, P., Dal Ben, M., Conti, C., Gazzin, S., & Tiribelli, C. (2017). Vitamin D, homocysteine, and folate in subcortical vascular dementia and alzheimer dementia. Frontiers in Aging Neuroscience, 9. https://doi.org/10.3389/fnagi.2017.00169

17 Farina, N., Jernerén, F., Turner, C., Hart, K., & Tabet, N. (2017). Homocysteine concentrations in the cognitive progression of alzheimer's disease. Experimental Gerontology, 99, 146–150. https://doi.org/10.1016/j.exger.2017.10.008

18 Farina et al. (2017) 

19 Mikkelsen et al. (2016)

20 Robinson et al. (2017)

21 Mikkelsen et al. (2016)

22 Ibid.

23 Farina et al. (2017)

24 Moretti et al. (2017)

25 Farina et al. (2017)

26 de Wilde, M. C., Vellas, B., Girault, E., Yavuz, A. C., & Sijben, J. W. (2017). Lower brain and blood nutrient status in alzheimer's disease: Results from Meta-Analyses. Alzheimer's & Dementia: Translational Research & Clinical Interventions, 3(3), 416–431. https://doi.org/10.1016/j.trci.2017.06.002

27 Robinson et al. (2017)

28 de Wilde et al. (2017)

29 Meng, Q., Lin, M.-S., & Tzeng, I.-S. (2020). Relationship between exercise and alzheimer’s disease: A narrative literature review. Frontiers in Neuroscience, 14. https://doi.org/10.3389/fnins.2020.00131

30 CHEN, W. E. I.-W. E. I., ZHANG, X. I. A., & HUANG, W. E. N.-J. U. A. N. (2016). Role of physical exercise in alzheimer's disease. Biomedical Reports, 4(4), 403–407. https://doi.org/10.3892/br.2016.607 

31 Ibid. 

32 Meng et al. (2020)

Mental Health Representation in Television & Film

Mental Health & Our Relationship With Film

As the television and film industry has expanded over the past century, filmmakers have increasingly turned to crafting the most sensational stories to bring in money at the box office.[1] Because television portrayals of atypical or dangerous characters have proven especially lucrative, American films often portray mental illness in ways that emphasize or exaggerate the otherness of characters.[2] Thus, severe mental illness has become overrepresented in film: filmmakers prefer the utility of mental illnesses such as antisocial personality disorder, dissociative identity disorder (DID), and schizophrenia in developing mass appeal narratives with "sensational" stories, effectively erasing more invisible mental illnesses such as social phobias and anxiety.[3,4] In fact, in a study of 60 top-grossing films, schizophrenia and DID were found to be distortedly overrepresented in comparison to their relative rarity in the real world.[5] In exaggerating the prevalence of severe mental illness, films can influence viewers to begin seeing such sensational stories as the reality of mental illness around them.

Our experience with film is not confined to the theater. Whether a passenger on the metro brings to mind a character from Netflix, or an office we visit is reminiscent of a movie scene, the media we consume is incorporated into our daily realities. "Film dominates the environment of the viewer, who interacts with the film psychophysically," writes film researcher O'Hara (2019).[6] Our immediate experience with a film is physical and visceral, experiencing emotions as sensations.[7] Subsequently, this hyperrealism within film can blur the lines between fiction and reality, a "mystification" causing us to incorporate flawed and even harmful representations into our understanding of certain groups and conditions.[8] 

Riles et al. (2021) find that routine exposure to popular messages, themes, and associations in film can influence viewers' judgment to make less systematic processing of content.[9] Riles (2020) explains this phenomenon: according to media priming theory, when a disparaging message is presented frequently, that message becomes more accessible in the mind of the viewer when encountering an individual meeting the criteria of that message via the availability heuristic.[10] Quintero Johnson & Riles (2018) add that mass media depictions can shape viewers' mental schema and enhance the accessibility of those schema, influencing their subsequent evaluations and behaviors.[11] With American films grossing more than 10 billion dollars USD at the box office annually, and with streaming services bringing film into our homes, media consumption has become one of the main pathways to expose Americans to these potentially harmful mass messages.[12] 

As many Americans use media as their primary source of information about mental illness, the exaggerated exposure perpetuates stigma towards disorders that are already misunderstood: recall of disparaging messages about mental illness when encountering individuals with mental illness is strongest when this message is "vividly" and "exaggeratedly" portrayed.[13] According to exemplification theory, representations of mental illness that are most extreme are also the most cognitively accessible.[14] In fact, vivid exposure to negative portrayals of mental illness is associated with stereotypical and stigmatizing perceptions of mental illness, less positive attitudes, and heightened social distance preferences towards people with mental illness.[15-17] These effects are widespread; a study by Quintero Johnson & Riles (2018) found that weekly television use predicted disproportionately higher estimates of the prevalence of both general and severe mental illness.[18] While the National Institute for Mental Health (NIMH) reports an 18.6% incidence of mental illness at any given time, participants estimated an incidence of 31%—close to twice as high.[19] Even worse were participants' estimates for severe mental illness. While the NIMH reports 4.1% of the population having serious mental illness, participants estimated that 14.7% of the population has severe illness—well over three times as high—and that 46% of those with mental illness are dangerous.[20] With television broadcasting highly dramatized caricatures of people with mental illness, viewers are incorporating those stereotypes into their conceptions of the population around them and perpetuating stigma towards mental illness. 

Prevalence of Othering Stereotypes

In addition to exaggeration, media representations can serve to alienate people with mental illness by using negatively charged, imprecise language and representations, such as using the word "crazy" to conflate different mental illnesses with one another.[21] In fact, in Quintero Johnson & Riles' (2018) study, a significant number of participants wrote "he acted like a crazy person" when asked to describe the characteristics and conditions of mentally ill media characters, noting abnormal speech patterns and unkempt or dirty appearances.[22] Such stigmatizing conceptions are othering towards people with mental illness and perpetuate their marginalization within society. As discussed by O'Hara (2019), films such as The Fisher King (1991) banish the mentally ill to the basement and other fringes of society, a depiction of behavioral and psychological disturbance as "craziness" and "monstrosity" that ostracizes this group.[23] Notions of mental illness as "craziness" can even cast doubt on the efficacy of therapy: Byrne (1997) discusses how stereotypes of psychiatrists, themselves, as "crazy" and ineffectual can parallel references to patients as "simple idiots" and "loonies."[24] In fact, Quintero Johnson & Riles (2018) found a negative association between television viewing and perceived benefits of talking to a mental health therapist.[25] 

Stereotypes of mental illness as incurable and all-consuming can also serve to alienate therapists and patients. Byrne (1997) discusses a second film stereotype of psychiatrists as "pitiable good fellows" trying to "cure the incurable," paralleling patient stereotypes as "poor wretches who cannot cope with life's adversities."[26] By casting a lens of pity and futility onto the realm of mental illness, films distance viewers from patients. Representations of mental illness disproportionately depict patients excessively struggling and participating in risky behaviors to cope, with muted success with dealing with their pressures in life.[27] In a study by Riles et al. (2021), 48% of mentally ill characters were depicted crying, 10% had their struggles diminished by others, and 5% attempted suicide, while 33% drank alcohol and 24% smoked cigarettes.[28] Such depictions perpetuate stereotypes of those with mental illness as weak and lacking willpower, or even as a lost cause. This can alienate viewers with mental illness and lead them to see these unhealthy coping representations as the only possible solutions or end results.[29] 

Overrepresentation of Violence and Danger

Another side to the misrepresentation of people with mental illness as less able to engage in healthy living and adversity management is the overrepresentation of characters as erratic, violent, and dangerous.[30] Doing so similarly discredits people with mental illness from social acceptance: in a survey of families of people with mental illness and their perceptions of what causes stigma, 86.6% blamed "popular movies about mentally ill killers."[31] This blame is not unfounded: a study by Quintero Johnson & Riles (2018) found that 72% of mentally ill television characters hurt or killed other characters and were ten times more likely to commit violent crime than other characters, despite the relatively low actual risk of violence among this population.[32-34] Riles et al. (2021) similarly found that 70% of characters with mental illness were associated with physical aggression, 55% with verbal aggression, and 12% with sexual aggression.[35] 

According to stigma theory, the "association of a particular social identity with physical or social threats and abnormalities is a potent means through which that identity can be disqualified from social acceptance."[36] With the media showcasing mental illness as synonymous with increased violence and danger, viewers begin to associate mental illness with fear and criminality. Especially with news reports tending to focus on the most sensational stories, reporting individuals with schizophrenia involved with major violent crimes, public attitudes towards people with mental illness are shifted towards greater preference for social distance.[37] Quintero Johnson & Riles (2018) corroborate this finding, discussing how when behaviors of a target character are labeled as mental illness, college students' perceptions about the dangerousness of and their desire for social distance from that person increase.[38] The lack of differentiation between psychotic (losing touch with reality) and psychopathic (exhibiting abnormal or violent social behavior) mental illness in popular media contributes to this desire for social distance, as people with mental illness are grouped into a single stereotype of violence.[39,40] 

Horror films are particularly notorious for crude and sensationalized depictions of mental illness as monstrous. Films as early as The Maniac Cook in 1909 and The Cabinet of Dr. Caligari in 1920 have held inaccurate and stigmatizing representations of psychosis, depicting mental health environments as cruel, prison-like Victorian institutions and their inhabitants as grotesque creatures and villains.[41] A study of 55 horror feature films made between 2000 and 2012 by Goodwin (2013) finds that similar stereotypes persist in films featuring psychosis today.[42] A troubling 78.78% of the films studied included the stereotype of a "homicidal maniac," while 72.73% featured "pathetic and sad characters" and 12.12% treated patients as "zoo specimens."[43] An additional 66.67% of films studied commonly used glass imagery to showcase fragility or a split personality, an othering depiction of a "whole self" that the patients have "lost."[44] Other stereotypes can be dismissive of the gravity of mental illness. These include horror films where harmless eccentricity is labeled as mental illness and inappropriately treated, in addition to 18.18% of films studied where supposedly delusional people were in fact telling the truth.[45] Such characterizations of mental illness can be misleading, dismissing the legitimacy of psychosis and its capacity to make its patients lose touch with reality. 

In addition to othering patients with mental illness, horror films can be highly stigmatizing towards mental health care professionals and institutions, further dissuading people from seeking treatment. In Goodwin's (2013) study, 51.11% of films featured dangerous hospital staff tackling clients with batons and tasers, along with 64.44% using some kind of restraint such as a straitjacket or chaining clients to a wall.[46] 37.77% of films included a stereotype of an evil doctor or nurse, and 35.55% involved boundary violations by the therapist in treating their patient. Within the mental health setting itself, 57.77% of films also included dirty and unhygienic environments, while 53.33% included haunted or supernatural hospitals patients needed to escape from. Harmful stereotypes also abound toward neurosurgery and biological psychiatric treatments in horror films, casting them as primitive tools that block creativity and intelligence; 28.89% of films studied included negative depictions of electroconvulsive therapy and lobotomies.[47] Such representations can be extremely harmful given the success rate of these psychiatric treatments for treatment-resistant mental health conditions. By contributing to misinformation about these treatments' stereotyped "barbarism," horror films stigmatize seeking life-saving help.

Romanticization of Mental Health Conditions

Another form of misrepresentation and sensationalization of mental health in film includes romanticization. In the effort to craft a compelling tale, film makers will often embellish, simplify, or decontextualize complex mental health conditions, resorting to unrealistic tropes where "willpower" or "love" can "conquer" mental illness.[48,49] O'Hara (2019) examines this sensationalization in studying A Beautiful Mind, a 2001 film telling the story of John Nash, a successful mathematician who won the Nobel Prize with paranoid schizophrenia.[50] From his study, O'Hara argues that the movie exhibits "schizophilia," a modernist tradition of "overvaluing madness" through prioritizing and sensationalizing Nash's psychiatric disorder over other aspects of his life. For example, the film places a large focus on vivid visual hallucinations, when in actuality Nash had auditory hallucinations as is most common in patients with schizophrenia. Through emphasizing twists, suspicions, and intrigues, the film becomes "a blindly dumb attempt to turn schizophrenia into an adventure for the audience … schizophrenia becomes an occasion for a cinematic magic trick that leaves the viewer with no concept of the difficulty in getting well."[51]

Perhaps the most harmful example of this romanticization comes with the film's choice of ending: in it, Nash stops taking his medication and decides to reject his hallucinations by simply refusing to interact with them. By doing so, his life becomes seemingly normal and controllable, and he wins the Nobel Prize.[52] This ending is highly misleading and serves more the purposes of a dramatic narrative than realistically portraying schizophrenia; by promoting the idea that schizophrenia can be cured with self-discipline, the film heavily simplifies mental illness and implies that patients with schizophrenia may just lack willpower. Like in the horror movies discussed earlier, this film similarly stigmatizes medication by making halting medication by personal choice appear to be the "brave" action, when in reality stopping medication usage can cause rapid relapse or withdrawal effects and should not be done without consulting a medical professional. 

Although not a mental illness, autism spectrum disorder (ASD) is a neurodevelopmental disorder with mental effects that are often depicted and misrepresented on screen. Because many people do not have substantial or direct contact with those on the spectrum, they often look to other sources, like film, to draw understanding.[53] This can have benefits and drawbacks: while some film representations of ASD are highly matched to diagnostic characteristics, fictional autistic characters showcase an overrepresentation of savant-like skills. In a study of 26 films and TV series featuring ASD across four continents, savant-like skills were reported in 46% of characters, when in fact savantism is estimated to exist in 10-30% of populations with ASD.[54] Although the inclusion of these skills can develop a character's value and capability within a dramatic narrative, the exaggerated representation can serve to romanticize the condition and propagate the message that these skills constitute a person with ASD's worth, when in fact only a minority of the population exhibit them. Another misrepresentation was noted in the 1999 film Molly, which depicts experimental brain surgery "curing" autism.[55] Though such a depiction again facilitates the resolution of a dramatic narrative, it contributes to attitudes towards autism as a disease and can be very stigmatizing towards people who identify as neurodivergent. 

Additional concerns can actually arise when ASD is represented correctly on screen. The majority of characters with ASD on screen typically show the maximum possible score on the DSM-5 symptom scale for ASD, acting as "archetypes" for the diagnostic criteria.[56] Although this shows diagnostic accuracy, it actually increases the likelihood of stereotyping by lacking nuance and does not fully represent the broad spectrum of experiences with ASD. Nordahl-Hansen et al. (2018) argue that films should not only show diagnostic accuracy, but also accurately portray the real-life obstacles faced by people on the spectrum in addition to what they can accomplish in a supportive environment, a fully fleshed out representation of their autonomy and personhood.[57] 

Other Inaccuracies in Representation

Films on mental health exhibit additional overarching misrepresentations. One of the largest concerns is that mental illness is predominantly portrayed in privileged majority populations: a study by Riles et al. (2021) found that 97% of characters with mental illness were white, 79% were male, 88% were adult-aged, 94% were heterosexual, and 72% were non-religious.[58] When the media fails to portray marginalized populations experiencing mental illness, it casts mental health as a "Caucasian phenomenon" and reinforces ideas in many minority populations that mental healthcare and therapy are also only for the majority populations.[59] Doing so also ignores the compounded effects of mental illness and marginalized identity, particularly with the higher likelihood for certain ethnic groups and LGBTQ+ youth to experience mental health conditions.[60] Increasing portrayal of minority groups with mental illness would also help to address an overall lack of representation: although 25% of adults experience mental illness, only 5% of film characters have a mental illness.[61] Increasing representation of mental health in film, in a thoughtful and accurate way, is crucial to help mediate this inaccuracy.

Moving Forward in Film

Moving forward, Goodwin (2013) recommends that the mental health sector work more closely with the film and television industry to reduce stigmatizing content and voice their opinions in advocacy groups.[62] Byrne (1997) concurs, suggesting setting up a mental health information service where complaints from interest groups and inquiries from the media could both be addressed.[63] During production, O'Hara (2019) suggests film makers consider a series of ethical questions: What effect will this portrayal have on the audience? Is this portrayal exploiting the lived experiences of persons with psychological disabilities? How does this portrayal engage with the agency, voice, and access of people with mental illness? If symptoms manifest differently in different patients, how can we depict the condition without reinforcing stereotypes and stigmatizing attitudes?[64] By making these considerations, films can reduce harm and exploitation of people with mental illness.

Another important way to combat misrepresentation begins with public education, especially in K-12 schools when children are forming their first conceptions of mental illness.[65] Byrne (1997) suggests disseminating mental health information through audiovisual packages for schools that have been regulated for accuracy.[66] O'Hara (2019) leans more towards developing critical thinking skills in children so that whether or not they end up consuming misrepresentative media, they can be more wary of its stereotypes and flaws.[67] O'Hara suggests incorporating discussions around deconstructing stereotypes and critical questioning skills in classrooms, and reminds us that "students viewing movies create meaning through their past experiences in relation to images on the screen."[68] In this way, mental health film can be used to instruct about equity if done well, including perhaps increased exposure to nonfiction films and documentaries on mental illness.[69] By starting education about mental illness and critical thinking early, teachers can help to dismantle stereotypes and lessen the stigmatizing effects of the media around us. 

Contributed by: Anna Kiesewetter

Editors: Jennifer (Ghahari) Smith, Ph.D. & Brittany Canfield, Psy.D.

References

1 O'Hara, M. (2019), Cinema of the Monstrous: Disability and “Eye-Feel”. Journal of Curriculum Theorizing, 34 (5): 44-57. https://journal.jctonline.org/index.php/jct/article/view/869. 

2 Ibid.

3 Riles, J.M., Miller, B., Funk, M., Morrow, E. (2021), The Modern Character of Mental Health Stigma: A 30-Year Examination of Popular Film. Communication Studies, 72 (4): 668-683. https://doi.org/10.1016/j.psychres.2017.08.050. 

4 Riles, J.M. (2020), The social effect of exposure to mental illness media portrayals: Influencing interpersonal interaction intentions. Psychology of Popular Media Culture, 9 (2): 145-154. https://psycnet.apa.org/buy/2018-58786-001. 

5 Riles et al. (2021)

6 O'Hara (2019)

7 Ibid.

8 Nordahl-Hansen, A., Tondevold, M., Fletcher-Watson, S. (2018), Mental health on screen: A DSM-5 dissection of portrayals of autism spectrum disorders in film and on TV. Psychiatry Research, 262: 351-353. https://doi.org/10.1016/j.psychres.2017.08.050. 

9 Riles et al. (2021)

10 Riles (2020)

11 Quintero Johnson, J.M., Riles, J.M. (2018), "He acted like a crazy person”: Exploring the influence of college students’ recall of stereotypic media representations of mental illness. Psychology of Popular Media Culture, 7 (2): 146-163. https://psycnet.apa.org/buy/2016-19244-001. 

12 Riles et al. (2021)

13 Riles (2020)

14 Quintero Johnson & Riles (2018)

15 Ibid.

16 Riles (2020)

17 Riles et al. (2021)

18 Quintero Johnson & Riles (2018)

19 Ibid.

20 Ibid. 

21 Riles (2020)

22 Quintero Johnson & Riles (2018)

23 O'Hara (2019)

24 Byrne, P. (1997), Psychiatric stigma: past, passing and to come. Journal of the Royal Society of Medicine, 90: 618-621. https://journals.sagepub.com/doi/pdf/10.1177/014107689709001107. 

25 Quintero Johnson & Riles (2018)

26 Byrne (1997)

27 Riles et al. (2021)

28 Ibid. 

29 Ibid. 

30 Ibid. 

31 Byrne (1997)

32 Quintero Johnson & Riles (2018)

33 Riles et al. (2021)

34 Riles (2020)

35 Riles et al. (2021)

36 Ibid. 

37 Riles (2020)

38 Quintero Johnson & Riles (2018)

39 Byrne (1997)

40 Goodwin, J. (2014), The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty-First-Century Horror Film (Part II). Perspect Psychiatr Care, 50: 224-234. https://doi.org/10.1111/ppc.12044 

41 Ibid.

42 Ibid. 

43 Ibid.

44 Ibid.

45 Ibid.

46 Ibid. 

47 Ibid. 

48 Ibid.

49 O'Hara (2019)

50 Ibid. 

51 Rockwell, C. (2002). A Beautiful Mind [Review of the motion picture]. Cineaste, 27(3). 36-37.

52 O'Hara (2019)

53 Nordahl-Hansen et al. (2018)

54 Ibid. 

55 Ibid.

56 Ibid. 

57 Ibid. 

58 Riles et al. (2021)

59 Ibid.

60 Mental Health America. (2022) https://www.mhanational.org/issues/lgbtq-communities-and-mental-health. 

61 Riles et al. (2021)

62 Goodwin (2013)

63 Byrne (1997)

64 O'Hara (2019)

65 Ibid. 

66 Byrne (1997)

67 O'Hara (2019)

68 Ibid.

69 Ibid.