Learning While Undocumented: Psychological Impacts of a Student’s Immigration Status

Who is considered undocumented?

Many people relocate to another country in search of better economic opportunities and superior education. In particular, undocumented students often have high academic aspirations to break cycles of poverty and seek to do something truly meaningful with their lives.[1] People may be considered undocumented if they are in the process of gaining legal status, have Deferred Action Childhood Arrival (DACA), have entered the United States without inspection, used fraudulent documents, or entered legally but stayed without authorization.[2] Some have arrived in the country as children with their parents, while others have decided to immigrate as young adults. In many cases, undocumented students were brought to the US as young children and this is the only country they really know and can call “home.” The absence of a clear path to legality can generate stress, anxiety, and frustration - all of which can be harmful to mental health.  

The Undocumented Students Mental Health Crisis 

Mental health is a significant public health issue in the United States, especially for young adults.  The Substance Abuse and Mental Health Association’s national data shows that in the past year, 30.6% of young adults aged 18-25 experienced a mental, behavioral, or emotional disorder, and 17% had a major depressive episode.[3] 

In addition to the mental health challenges of being a young adult, there are also the challenges associated with being a student, which is even more difficult for those with an uncertain immigration status. As there is no federal law prohibiting undocumented students from attending college or university, many institutions review all prospective students under the same admissions criteria regardless of status.[4] Thus, over 427,000 undocumented college students are enrolled in U.S. colleges and universities, and research confirms that their immigration status negatively impacts their well-being due to psychosocial challenges.[5] 

Enriquez (2019) notes that undocumented students' well-being is often impacted by the additional stressors of limited financial resources due to restricted job opportunities, fear of deportation for self and others, uncertainty about the future, and stigmatization.[6] Torres (2022) found that undocumented students have significantly higher stress levels than students who are U.S. citizens or protected under DACA, likely due to immigration fears.[7] Additionally, Cadenas (2022) explored the impacts of insecure immigration status on college students and found that precarious immigration status was linked to lower perceptions of welcoming campus climate, lower positive mental health, and higher anxiety.[8] Another challenge that undocumented students face is whether to disclose their immigration status due to the potentially negative consequences they feel they may incur.[9]

Age of Arrival

The pursuit of education while undocumented is not the same for every undocumented student, as several factors create a unique learning experience or hurdle. Cha (2019) found significant disadvantages faced by students arriving at a later age than those who have had the majority of their K-12 schooling completed in the United States. Notably, those arriving in their late teens to early twenties often had below-level course placement, less time to learn the US education system, and often a lack of access to ethnically-similar peers outside of ESL courses.[10] Furthermore, forming positive relationships with school agents did not enable them to surmount the aforementioned structural barriers.[11]

The DACA Impact

Established in 2012, the Deferred Action Childhood Arrival (DACA) program provides renewable two-year access to work permits and protection from deportation to approximately 653,000 immigrants in the United States.[12,13] If an individual meets the eligibility requirements they can apply for the DACA program by submitting the application through the U.S. Citizenship and Immigration Services website.[14] The eligibility requirements for the DACA program are as follows:[15]

• Were under the age of 31 as of June 15, 2012

• Have entered the U.S. before turning 16 years old

• Have continuously resided in the U.S. since June 15, 2007 up to the present time

• Have been physically present in the U.S. on June 15, 2012 and at the time of application for DACA

• Have had no lawful immigration status on June 15, 2012

• Currently enrolled in school (or have returned to school), graduated, obtained certificate of completion (e.g., GED) OR be an honorably discharged U.S. veteran

• Have not been convicted of a felony offense, a significant misdemeanor offense, multiple misdemeanor offenses, or otherwise pose a threat to national security or public safety

Thus, an undocumented person can apply to the DACA program and gain temporary legal status by being an active or graduate student in the U.S., by obtaining a GED, or being honorably discharged from the military. Being a DACA recipient helps to overcome some of the structural barriers created by illegal status. According to a study by Cha (2019), DACA recipients report improved high school and college completion rates, higher-paying jobs with better working conditions, eligibility to obtain bank accounts and driver's licenses, and better overall psychological well-being.[16] Further research by Torres (2022) found that undocumented students reported significantly greater stress than citizens, while DACA recipients' stress levels did not differ from those of United States citizens.[17] 

Protection under DACA allowed recipients to spend less time in "survival mode," as found by a review conducted by Siemons (2017), thus enabling them to devote more time and energy to meeting higher-level needs such as fulfilling higher education goals.[18] Even though DACA does not grant permanent legal status, it is renewable every two years. DACA aims to provide a safe environment for these individuals to pursue higher education and better-paying jobs which could lead to sponsorship opportunities for permanent legal status or longer-term work visas.

Seeking Help

Undocumented students often face obstacles when trying to access the support they need to overcome structural barriers. According to Cha (2019), these students are less-likely to use their college mental health services due to various reasons such as: low perceived need (as mental strain is often normalized within immigrant communities); a sense of futility (as they may believe that treatment would not address the underlying immigration issues); or fear of being stigmatized for mental health issues or immigration status.[19] 

Ayon's (2022) research found that greater perceptions of social exclusion due to the immigration policy context predicted lower use of on-campus mental health services by undocumented students.[20] However, when students encountered greater levels of mental health symptoms, perceived mental health needs, and campus-wide resources were available, undocumented students then had a greater likelihood of using on-campus mental health resources.[21] Further, a review by Butt in 2023 found that creating student organizations or support groups for undocumented students can help create a more welcoming and inclusive campus environment, thus making them more likely to seek help through on-campus services.[22] These changes can be especially important and impactful as it’s crucial to address one’s mental health struggles before they reach peak levels of distress. 

Undocumented students face numerous challenges while pursuing higher education, but continue to work towards their education since it can lead to significant benefits. A higher degree can lead to better-paying job opportunities and possible sponsorship for a long-term visa or permanent legal status. While a degree from a U.S. institution is recognized in many foreign countries, many undocumented immigrants who seek higher education in the U.S. have lived there for most of their lives and consider it their home. Therefore, as a society, it is beneficial to promote and foster good mental health resources for undocumented students as they often aspire to stay within the U.S. post-graduation to continue to improve their lives in the country they grew up in and feel a part of, while also “giving back” to the community they live in. 

Contributed by: Maria Karla Bermudez

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

References

1 Butt, M., & Brehm, C. (2023). Seeking Access: Role Strain, Undocumented Students, and the Pursuit of College. The International Journal of Educational Organization and Leadership, 30(2), 67-86. https://doi.org/10.18848/2329-1656/CGP/v30i02/67-86

2 Who are undocumented students? - immigrants rising. Immigrants Rising. (2023, October). https://immigrantsrising.org/wp-content/uploads/Immigrants-Rising_Overview-of-Undocumented-Students.pdf 

3 Substance Abuse and Mental Health Services Administration. 2020. “Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health.” https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.

4 Undocumented student frequently asked questions: Applying to the UW. Admissions. (n.d.). https://www.washington.edu/admissions/undocumented/undocumented-faq/#:~:text=There%20is%20no%20federal%20or,admissions%20criteria%20regardless%20of%20status 

5 Nienhusser, H. K., & Romandia, O. (2022). Undocumented college students' psychosocial well-being: A systematic review. Current opinion in psychology, 47, 101412. https://doi.org/10.1016/j.copsyc.2022.101412

6 Enriquez, Laura E. 2019. “Border Hopping Mexicans, Law-Abiding Asians, and Racialized Illegality: Analyzing Undocumented College Students’ Experiences through a Relational Lens.” Relational Formations of Race: Theory, Method and Practice. Edited by Natalia Molina, Daniel Martinez HoSang, and Ramón A. Gutiérrez. University of California Press.

7 Torres, A., Kenemore, J., & Benham, G. (2022). A Comparison of Psychological Stress and Sleep Problems in Undocumented Students, DACA Recipients, and U.S. Citizens. Journal of Immigrant and Minority Health, 24(4), 928-936. https://doi.org/10.1007/s10903-021-01315-3

8 Cadenas, G. A., Nienhusser, K., Sosa, R., & Moreno, O. (2022). Immigrant students' mental health and intent to persist in college: The role of undocufriendly campus climate. Cultural diversity & ethnic minority psychology, 10.1037/cdp0000564. Advance online publication. https://doi.org/10.1037/cdp0000564

9 Butt & Brehm (2023)

10 Cha BS, Enriquez LE, Ro A. Beyond access: Psychosocial barriers to undocumented students' use of mental health services. Soc Sci Med. 2019 Jul;233:193-200. doi: 10.1016/j.socscimed.2019.06.003. Epub 2019 Jun 5. PMID: 31212126.

11 Ibid.

12 Ibid.

13 Torres et al. (2022)

14 Steps to apply for DACA for the first time. IMMIGRANTS RISING. (2022, December 2). https://immigrantsrising.org/resource/steps-to-apply-for-daca-for-the-first-time/ 

15 Ibid.

16 Cha et al. (2019)

17 Torres et al. (2022)

18 Siemons R, et al. Coming of age on the margins: Mental health and wellbeing among Latino immigrant young adults eligible for Deferred Action for Childhood Arrivals (DACA). J Immigr Minor Health. 2017;19(3):543–51.

19 Cha et al. (2019)

20 Ayón C, Ellis BD, Hagan MJ, Enriquez LE, Offidani-Bertrand C. Mental health help-seeking among Latina/o/x undocumented college students. Cultur Divers Ethnic Minor Psychol. 2022 Dec 15. doi: 10.1037/cdp0000573. Epub ahead of print. PMID: 36521136.

21 Ibid.

22 Butt & Brehm (2023)

Mind-Body Therapies for Improving Mental Health

Mind Over Matter

Mind-body therapies, also known as complementary health approaches (CHAs) are a diverse group of healthcare practices and healing techniques focused on the integration of mind, body, brain, and behavior.[1] While mind-body therapies treat a variety of acute and chronic health conditions, there has been renewed interest in ancient traditions, such as yoga and meditation, to treat mental health conditions like depression and anxiety.

These therapies serve as complementary adjuncts to conventional forms of mental health treatment. “Complementary” medicine differs from “alternative” medicine in the sense that complementary medicine is utilized together with other forms of medicine whereas alternative medicine serves as a complete replacement. While both have historically drawn some skepticism as their origins lie outside of typical Western modes of treatment, complementary medicine has been shown to effectively bridge various forms of therapy in a coordinated way. Moreover, mind-body therapy provides a low intensity and accessible therapy and treatment option for a wide variety of individuals, including those in marginalized populations and disadvantaged individuals who may not otherwise receive mental health treatment.[2] 

Health Benefits 

The goal of mind body therapy is to lower levels of stress hormones to improve overall health and reduce risk of chronic illness. With heightened levels of stress, one is at greater risk for several diseases including high blood pressure, heart irregularities, anxiety, insomnia, persistent fatigue, digestive disorders, diminished fertility, and diabetes.[3] 

Mount Sinai’s Icahn School of Medicine states that mind-body techniques can encourage relaxation, improve coping skills, reduce tension and pain, and lessen the need for medication.[4] Specifically related to improvements in mental health, it has been posited that mind-body practices can foster a sense of control, increase optimism, and provide social support that improves one’s quality of life and reduce symptoms related to depression and anxiety.[5] In addition, the National Center for Complementary and Integrative Health (NCCIH) believes that multiple modes of treatment can better treat the whole person rather than administering a treatment for one single organ.[6]

Types of Mind-Body Therapies

There are several types of Mind-Body Therapy as defined by the NCCIH, however the most popular are yoga, tai-chi, and qigong, followed by meditation and massage therapy.[7,8] 

Low-Intensity & Movement-Based: 

1. Yoga: Yoga has its origins in an ancient healing practice in India known as Ayurveda, and draws upon the intersection of movement through postures, mindful breathing and meditation, and well as an emphasis on personal and spiritual growth. A typical yoga practice moves through a series of poses to help strengthen the physical body as well as establish a stronger connection to one’s own interiority (i.e., mind to muscle connection). Yoga is one of the most utilized and effective forms of mind-body therapy. It has been shown to increase feelings of relaxation, improve self-confidence and body image, and induce feelings of optimism and well-being.[9] 

2. Tai Chi: Tai chi has its roots in ancient Chinese philosophy and traditional medicine theory that focuses primarily on controlling breath and internal energy. Tai chi features specific exercises that improve balance, mobility, and stamina and is also effective in treating stress and anxiety disorders through the encouragement of bodily awareness. Tai chi has been posited to have similar effects to Cognitive Behavioral Therapy (CBT), specifically in its ability to treat insomnia. A study by Raman et al. (2013) showed that older adults with chronic conditions who practiced tai chi reported improved sleep quality and better psychological well-being.[10]

3. Qigong: Qigong is an ancient Chinese healing practice which integrates bodily movements and muscle relaxation with breathing techniques and meditation that strengthen one’s connection to their internal vital energy force. Qigong can stabilize both sympathetic and parasympathetic nervous system activity in order to reduce blood pressure and feelings of stress and anxiety. Related to improvements in cognitive function, qigong has been shown to improve both processing speed and sustained attention in older adults.[11]

Encourage Physical & Mental Relaxation:  

1. Acupuncture: Acupuncture has its roots in traditional Chinese medicine and healing systems. This practice draws from the belief that one’s qi or energy (similar to the energetic life force which generates the movements of qi-gong) flows along channels that connect different parts of the body in a synergetic way. When this energy becomes stagnant, individuals may experience pain or psychological distress related to anxiety, depression, and insomnia. Acupuncture stimulates areas of the brain known to reduce sensitivity to pain and stress as well as promote relaxation by activating the parasympathetic nervous system, which initiates the relaxation response.[12]

2. Aromatherapy: Aromatherapy utilizes the scent of plant oils and extracts to promote relaxation by engaging specific brain pathways.[13] Since olfactory smell receptors have signaling pathways connected to the brain, aromatherapy engages the parasympathetic nervous system to promote relaxation and also encourages the brain to produce more chemicals like serotonin or dopamine which are primarily responsible for controlling mood.[14] Memorial Sloan Kettering Cancer Center notes that aromatherapy using lavender or sweet marjoram may help anxiety. Additionally, they found that aromatherapy combined with massage was preferred to cognitive behavior therapy, but with similar benefits on lessening distress in cancer patients.[15]

3. Massage: Massage therapy promotes circulation, muscle relaxation, and alleviates stress through the manipulation of muscles and soft tissues in the body. It has also been posited that massage therapy can lower the production of the stress hormone cortisol in the body while releasing serotonin to boost mood and feelings of well-being. In addition to regulating breathing and improving sleep, the Mayo Clinic Health System notes that massage can help alleviate stress, anxiety, depression, nausea, pain, fatigue, and insomnia in cancer patients.[16] 

4. Meditation: Meditation is a widely used and empirically-proven effective therapy technique focused on the reestablishment of mind to body and breath. While it is relatively easy to implement a few minutes of meditation into one’s daily routine, meditation therapy is often offered as a structured 8 week program known as mindfulness-based stress reduction (MBSR). Meditation has been shown to improve mental functioning, self-awareness, mood, and well-being. The most common goals of meditation include inner calmness, physical relaxation, psychological balance, and improved vitality and coping.[17]

5. Guided Imagery: Guided imagery involves the recreation of mental imagery, sounds, and smells to ease anxiety and reduces feelings of depression, stress, fatigue, and discomfort. Practicing visualization and utilizing mental imagery can elicit a positive mood and greater feelings of calm and joy. Guided imagery is often used in conjunction with or implemented into meditation or yoga sessions with the help of a licensed instructor. For example, in a typical session, the practitioner helps the client enter a state of deep relaxation via breathing techniques, music, and/or progressive muscle relaxation in a quiet environment.[18]

The mind-body therapies listed above are all unique and vary widely in terms of their mechanism of action and origin, however, all of these therapies are considered low-intensity and sustainable practices that promote well-being, mental and physical relaxation, and a stronger connection to one’s body.[19] With guidance from licensed professionals, these therapies can effectively address the social, spiritual, and behavioral factors in one’s personal life in order to elicit better mental health. 

Contributed by: Kaylin Ong

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

references

1 Integrative Medicine: About Mind-Body Therapies | Memorial Sloan Kettering Cancer Center. (n.d.). Www.mskcc.org. https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/mind-body 

2 Burnett-Zeigler, I., Schuette, S., Victorson, D., & Wisner, K. L. (2016). Mind–Body Approaches to Treating Mental Health Symptoms Among Disadvantaged Populations: A Comprehensive Review. Journal of Alternative and Complementary Medicine, 22(2), 115–124. https://doi.org/10.1089/acm.2015.0038

3 Mind-Body Therapies | Taking Charge of Your Health & Wellbeing. (2016). Taking Charge of Your Health & Wellbeing. https://www.takingcharge.csh.umn.edu/explore-healing-practices/what-are-mind-body-therapies 

4 Mind-body medicine Information | Mount Sinai - New York. (n.d.). Mount Sinai Health System. https://www.mountsinai.org/health-library/treatment/mind-body-medicine#:~:text=What%20is%20mind%2Dbody%20medicine%20good%20for%3F 

5 Mind-Body Therapies | Taking Charge of Your Health & Wellbeing. (2016)

6 National Center for Complementary and Integrative Health. (n.d.). NCCIH. https://www.nccih.nih.gov/ 

7 Ibid.

8 Integrative Medicine: About Mind-Body Therapies | Memorial Sloan Kettering Cancer Center. (n.d.). Www.mskcc.org. https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/mind-body 

9 Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4(2), 49–54. https://doi.org/10.4103/0973-6131.85485 

10 Vincent J Minichiello, Y. Z. (2013). Tai Chi Improves Sleep Quality in Healthy Adults and Patients with Chronic Conditions: A Systematic Review and Meta-analysis. Journal of Sleep Disorders & Therapy, 02(06). https://doi.org/10.4172/2167-0277.1000141 

11 Qi, D., Wong, N. M. L., Shao, R., Man, I. S. C., Wong, C. H. Y., Yuen, L. P., Chan, C. C. H., & Lee, T. M. C. (2021). Qigong exercise enhances cognitive functions in the elderly via an interleukin-6-hippocampus pathway: A randomized active-controlled trial. Brain, Behavior, and Immunity. https://doi.org/10.1016/j.bbi.2021.04.011 

12 Anxiety. (n.d.). British Acupuncture Council. Retrieved October 17, 2023, from https://acupuncture.org.uk/fact-sheets/anxiety-and-acupuncture-factsheet/ 

13 Aromatherapy: Do essential oils really work? (2019). John Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/aromatherapy-do-essential-oils-really-work 

14 Camille Noe Pagán. (2018, January 11). What Is Aromatherapy? WebMD; WebMD. https://www.webmd.com/balance/stress-management/aromatherapy-overview 

15 Aromatherapy. (2016). Memorial Sloan Kettering Cancer Center. https://www.mskcc.org/cancer-care/integrative-medicine/therapies/aromatherapy 

16 Massage helps anxiety, depression. (n.d.). Mayo Clinic Health System. https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/massage-for-depression-anxiety-and-stress 

17 Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. Journal of Psychosomatic Research, 57(1), 35–43. https://doi.org/10.1016/s0022-3999(03)00573-7  

18 Guided Imagery | Memorial Sloan Kettering Cancer Center. (n.d.). Www.mskcc.org. https://www.mskcc.org/cancer-care/integrative-medicine/therapies/guided-imagery 

19 Mind-Body Therapies. (n.d.). Crohn’s & Colitis Foundation. Retrieved October 17, 2023, from https://www.crohnscolitisfoundation.org/complementary-medicine/mind-body-therapies#:~:text=Mind%2Dbody%20therapies%20focus%20on 

Addressing Mental Health Amongst First Responders: Sometimes Superheroes Need Saving, Too

Hidden Anguish

First responders play a vital and commendable role in society as they display exceptional bravery to save the lives of others, often at the risk of their own. Many first responders encounter unimaginable tragedy and horror on a daily basis, and then are expected to go home and attend to their loved ones. However, separating work from personal life may not be so easy for these individuals as the impact that traumatic events can have on one’s mental health is often left unacknowledged. Frequent exposure to death and tragedy undoubtedly affects one’s psychological state of well-being, including post-traumatic stress disorder (PTSD), substance abuse, depression and especially suicidal ideations. However, along with the societal expectation of first responders to be brave and strong, comes the suppression of such mental health problems and lack of proper psychiatric treatment.[1] 

Risk factors & Causes 

In comparison to the general population, first responders such as law enforcement officers (LEO), emergency medical technicians (EMT), and firefighters are at a greater risk of suicide ideation and suicide. Stanley et. al. (2016) conducted a systematic review of 63 quantitative studies examining the suicidal thoughts, behaviors, and fatalities of first responders, and found them to be at a significantly higher risk than general population samples.[2] Bond & Anestis (2021) conducted a study which showed that 23-25% of LEOs and 46.8% of firefighters experience suicidal ideations, and 10.4% of EMTs report severe lifetime suicidal ideation.[3] Frequent and severe traumatic experiences also lead to a higher risk of PTSD. Approximately 32% of LEOs, 22% of EMTs and 32% of firefighters experience PTSD. In comparison to the general civilian population, out of whom only 7-12% experience PTSD, these rates are concerningly high. There are also various risk factors amongst first responders that can contribute to their increased risk of developing PTSD, including:[4]

• Family history of psychiatric disorders

• Childhood trauma (abuse/adversity)

• Intelligence level

• Education

• Early conduct problems

Proper sleep hygiene (due to long and demanding shift schedules) also plays a role in the increased rates of disorders such as PTSD, depression, and anxiety. A longitudinal study conducted by Feldman et al. (2021) included 135 emergency medical service providers and recorded changes in symptoms of various psychological disorders over the course of 3 months. Their findings revealed that the increase in symptoms of PTSD, depression, and anxiety were all correlated with a poor sleep pattern and lower social support.[5] Erratic sleep patterns are especially problematic given that they compromise inflammatory and physiological stress responses.[6]

Acute stress disorder (ASD) is another common psychiatric disorder among first responders who experience frequent and high-impact stressors. A few pertinent symptoms of this disorder include:[7]

• Hyperarousal

• Negative mood

• Anger/irritability

• Dissociation

• Avoidance

• Numbing

• Nightmares

• Intrusive thoughts

ASD is developed once an acute stress response leads to more serious impairments after exposure to a traumatic stress with documented biological or psychological sequelae. Within 3 days of the traumatic event, multiple symptoms within five diagnostic categories will appear. ASD is signified by persistent symptoms well beyond the time frame of an acute stress reaction, which is more common and normal for anyone who experiences a traumatic event. While first responders who are acutely impacted by a trauma may develop ASD, developing ASD puts them at a greater risk for subsequently developing PTSD.[8]

The Three-Step Theory 

Not only do first responders experience greater rates of suicidal ideations, but they are also more likely to actually perform suicidal attempts.[9] Ideation-to-action is outlined by the Three-Step Theory (3ST), which states that there are three subcategories of capability that can shift an individual from suicidal thoughts to actual suicidal actions. These subcategories include:[10]

1. Practical - Broader knowledge of lethal weapons/drugs, and potentially even better access to them. The means of suicidal means are more readily obtainable. 

2. Dispositional - Innate tolerance to death and pain. 

3. Acquired - Learned desensitization and tolerance to death and pain. Having encountered numerous tragic events has built a sense of fearlessness in many first responders.

Suffering in Silence

Since a large majority of first responder suicides go unreported by mainstream media, there is an ongoing lack of knowledge/awareness of the general public to the degree that it occurs.  In addition, barriers exist that prevent first responders from accessing the proper psychiatric care they need when experiencing depression or suicidal ideations. Such barriers include shame and stigma surrounding mental health issues within their professions, as the concept of bravery and courage is heavily instilled upon them during training and work. Moreover, first responders and their families often fail to have open discussions about mental health, which unfortunately fuels the lack of awareness on the issue of first responder suicide.[11] 

Even when a first responder recognizes they are in crisis, several factors often prevent them from seeking adequate help: lack of knowledge on where/how to seek help, fear of confidentiality breach, belief that they cannot show weakness, lack of access and availability to therapy, family burden, pride and denial.[12] Destigmatizing mental health issues and spreading awareness is the first crucial step to ensuring that first responders are able to comfortably and willingly ask for help.[13] First responders should also be informed about mental health disorders and how to facilitate help-seeking.[14]

First responders are often expected to prevent their traumatic experiences from interfering with their professional and personal lives. The culture of first responders may prevent them from seeking actual mental health interventions, due to stigma and self-image. However, doing so often leads to unhealthy coping mechanisms such as substance abuse and high-risk behavior as an outlet for their stressors. Some also practice avoidance, leading to absenteeism in work and home, causing tension with their personal relationships. Conflict may even arise between colleagues, as high-stress environments and internal stressors combine together to create overall tension in the workplace. Therefore, psychoeducation to reduce stigma and subcultural barriers could help encourage first responders to seek treatment. This would eventually remediate their own psychological health and mend other impacted professional and personal relationships in their lives.[15] 

Building Resilience 

High resilience has been shown to be associated with lower symptomology of PTSD, depression, and alcohol abuse in active first responders. Therefore, resilience screening can help to protect the long-term mental health of first responders. High resilience indicates the ability to better tolerate problems, illness, failure, pressure, and feelings of pain.

These adaptive qualities of resilience can be developed in first responders via targeted interventions, including cognitive behavioral therapy (CBT) and mindfulness training programs. These two methods have been proven effective in increasing adaptive resilience amongst health professionals, factory workers, civil servants, and even breast-cancer patients. Employing resilience screening as a first responder begins work, one can identify which workers can most benefit from these targeted interventions to increase resilience, thus decreasing their chances of developing debilitating psychological disorders.[16] 

Thompson and Drew (2020) developed a 21-day program to enhance first responder resilience and tested the program with promising results. Every day over the course of 21 days, participants received a keyword which encouraged them to follow certain practices for the day, such as grit, calm, empathy, and gratitude. They also did 5 minutes of controlled breathing exercises, short readings on the keywords, reflections for the day, and an evening gratitude practice. Gratitude was incorporated into the program to increase sleep quality, life satisfaction, and decrease risk of depressive symptoms. In total, the practice work took only 15 minutes a day, accounting for the busy schedules of typical first responders. The participants responded to the 21 day course well, and a majority indicated that they would continue to use the practices they learned during the course of the program.[17]

Programs such as this one, and other resilience programs, would be beneficial for all first responders to incorporate into their lifestyles to increase resilience against developing mental health issues, promote the necessity of managing one’s mental health and reduce stigma in those suffering with PTSD, depression, anxiety and other work-related mental health disorders. 

If one has been suffering from any mental health disorder due to traumatic stress, such as PTSD or ASD, or is experiencing feelings of heightened anxiety or suicidal ideations, it is crucial to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Udyaver

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

References 

1 Heyman, M., Dill, J., & Douglas, R. (2018, April). The ruderman white paper on mental health and suicide of first ... https://firefightermentalhealth.org/system/files/First%20Responder%20White%20Paper_Final.pdf 

2 Stanley, I., Hom, M., & Joiner, T. (2015, December 12). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, emts, and Paramedics. Clinical Psychology Review. https://www.sciencedirect.com/science/article/abs/pii/S0272735815300684?via%3Dihub 

3 Bond, A., & Anestis, M. (2021, October 26). Understanding capability and suicidal ideation among first responders. https://www.tandfonline.com/doi/full/10.1080/13811118.2021.1993397 

4 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harvard review of psychiatry, 26(4), 216–227. https://doi.org/10.1097/HRP.0000000000000176 

5 Feldman, T. R., Carlson, C. L., Rice, L. K., Kruse, M. I., Beevers, C. G., Telch, M. J., & Josephs, R. A. (2021). Factors predicting the development of psychopathology among first responders: A prospective, longitudinal study. Psychological Trauma: Theory, Research, Practice, and Policy, 13(1), 75–83. https://doi.org/10.1037/tra0000957 

6 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

7 Ibid.

8 Ibid.

9 Bond, A., & Anestis, M. (2021, October 26). 

10 Heyman, M., Dill, J., & Douglas, R. (2018, April).

11 Stanley, I., Hom, M., & Joiner, T. (2015, December 12).

12 Jones S, Agud K, McSweeney J. (2020) Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness.” Journal of the American Psychiatric Nurses Association. 26(1):43-54. doi:10.1177/1078390319871997

13 Heyman, M., Dill, J., & Douglas, R. (2018, April).

14 Jones S, Agud K, McSweeney J. (2020)

15 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

16 Joyce, S., Tan, L., Shand, F., Bryant, R., & Harvey, S. (2019). Can resilience be measured and used to predict mental... : Journal of Occupational and Environmental Medicine. LWW. https://journals.lww.com/joem/abstract/2019/04000/can_resilience_be_measured_and_used_to_predict.4.aspx 

17 Thompson, J., & Drew, J. M. (2020, July 27). Warr;OR21: A 21-day program to enhance first responder resilience and mental health. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02078/full 

The Unseen Wounds of Dating Violence on Mental Health

Silent Scars

Dating violence is a pervasive issue that inflicts profound wounds on victims, both visible and hidden. The National Coalition Against Domestic Violence reports that 1 in 3 women and 1 in 4 men have experienced intimate partner physical violence such as slapping, injury and sexual abuse.[1] These issues can be difficult to notice from the outside of a relationship, allowing abuse to continue while mental scars shape victims' psychological and physical well-being. The connections between dating violence, abuse, and mental health shed light on the silent struggles endured by survivors.

The Spectrum of Abuse

Abuse in dating relationships takes on various forms - from physical violence to emotional manipulation, coercion, and even digital harassment. The dynamic that leads to violence in a relationship is a power imbalance when one person gains power and control over the other.[2] This may take the forms of threats, intimidation, financial abuse, stalking and isolation[3] and this multifaceted spectrum of dating violence can leave victims feeling trapped in a cycle of abuse. Dating violence shatters victims' sense of security, trust, and self-worth, planting the seeds for lasting mental health challenges. 

Examples of the warning signs of abusive behaviors include:[4]

• Using force or coercion to initiate sexual activity

• Attempting to isolate one from their family or friends

• Using threats

• Breaking objects, creating noise or yelling to establish intimidation 

• Having a history of abuse in past relationships 

• Expressing control financially (refusing for a partner to work)

• Expressing control over where a partner goes, what they wear, who they speak to...

• Frequent mood swings and shifts when in public compared to in private

• Constant jealousy 

Erosion of Emotional Well-being

The emotional toll inflicted by dating violence relates to poor mental health outcomes. Adolescent dating violence is particularly prevalent (i.e., 1 in 3 adolescents have experienced an abusive or unhealthy relationship) and is a predictor of partner violence as an adult.[5,6] Pérez-Marco et al. (2020) note that adolescents characterized dating violence as psychological, sexist, and verbal types of violence.[7] For example, blackmailing or damaging a partner’s dignity are examples of psychological violence.[8] Further, Piolanti et al. (2023) note that adolescent dating violence contributes to increased risk-taking behaviors such as marijuana and alcohol use, and negative mental health such as victimization, a common result of physical or emotional abuse.[9] These poor outcomes were more common among females when compared to males. Additionally, among 116 married women experiencing domestic abuse, Malik et al. (2021) found that abuse was associated positively with depression, anxiety and stress.[10] Domestic abuse was also related to a decreased quality of life.[11] The constant undercurrent of fear, anxiety, and uncertainty from degradation and physical attacks can erode victims' emotional well-being and even skew the perception of their relationship as being “normal” amidst high psychological distress.

Emotional abuse is related to:[12]

• Social anxiety

• Depression 

• Eating disorders

• Post Traumatic Stress Disorder (PTSD)

• Chronic pain

• Shame

• Self-doubt

• Low self-esteem

• Codependency 

Complex Trauma & Misconceptions of Dating Violence

Exposure to dating violence often inflicts complex trauma, or unique forms of psychological injury that can lead to enduring emotional and mental turmoil. The patterns of abuse – the relentless cycle of tension, explosion, and reconciliation – carve a pattern of fear in victims' minds. Complex trauma can manifest as post-traumatic stress disorder (PTSD), anxiety disorders and depression.[13] From an external perspective, relationship violence is commonly misunderstood as bystanders may question why a victim stays in their violent relationship if they are being abused. It is so easy to ask, “Why don’t they just leave?”[14] However, there is a deep manipulative aspect to dating violence that maintains a harmful cycle.

De Sousa et al. (2023) found that among participants ages 15-22 in relationships, control tactics were predominantly isolation, domination, and emotional manipulation.[15] These controlling dynamics establish heavy power imbalances that lead to both a bystander's and a victim's blindness to the harm of a relationship. For example, an abusive partner may conceal their violent tendencies when in public or around peers, but when in private with their partner, inflict abuse. The victim may even develop learned helplessness, in which they have repeatedly experienced violence and eventually stop resisting or trying to change the uncontrollable circumstance. Additionally, it is common for victims to find comfort in their abusive relationship, as they are manipulated to believe that they abuse because their partner “loves them,” as Shawn Guy writes for Genesis Women’s Shelter in an article about teen dating violence.[16] This occurrence is sometimes referred to as Stockholm syndrome, or the psychological response of a positive connection to an abuser.[17]

The Path to Recovery: Empowerment and Support

Victims of dating violence find it challenging to escape their abusers. Feelings of shame, guilt, and societal stigma can create barriers to seeking help. Additionally, financial dependence and isolation enforced by abusers can make it difficult for victims to end relationships.

Professional help through therapy can help survivors regain a sense of agency and control over their lives to minimize the long-term effects of abuse and trauma. For example, Karakurt et al. (2022) found that cognitive-behavioral therapy (CBT), mindfulness, motivational interviewing and expressive writing have led to successful results in increasing empowerment among women who had experienced intimate partner violence.[18] These modalities lowered stress and depressive symptoms, as well.[19]

Empowerment becomes a sign of hope as victims rebuild their self-worth as Pérez-Marco et al. found that empowerment skills were an effective resource to combat negative outcomes of abuse.[20] Treatment for perpetrators of domestic violence is less researched, but also integral to preventing relationship violence and subsequent mental health challenges. Taking into consideration social, societal and developmental contexts may be involved in methods to address high levels of violence exhibited by abusers as well as equitable access to treatment.[21,22]

Dating violence and abuse result in devastating impacts on victims' mental health, inflicting trauma that may never fully fade without proper intervention. By amplifying awareness, education, and access to mental health resources, society can stand against the silent scars left by dating violence and empower survivors on their journey toward recovery.

If one is experiencing any form of abuse or mental health challenges due to a relationship, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

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

References

1 National Coalition Against Domestic Violence. National Statistics. https://ncadv.org/STATISTICS#:~:text=NATIONAL%20STATISTICS&text=On%20average%2C%20nearly%2020%20people,10%20million%20women%20and%20men.

2 Washington University in St. Louis. (2023). What is Relationship and Dating Violence? https://students.wustl.edu/relationship-dating-violence/

3 Ibid.

4 Ibid.

5 Liz Claiborne Inc and The Family Fund. Teen Dating Abuse 2009 Key Topline Findings. http://nomore.org/wp-content/uploads/2014/12/teen_dating_abuse_2009_key_topline_findings-1.pdf 

6 Piolanti, A., Waller, F., Schmid, I. E., & Foran, H. M. (2023). Long-term Adverse Outcomes Associated With Teen Dating Violence: A Systematic Review. Pediatrics, 151(6), e2022059654. https://doi.org/10.1542/peds.2022-059654 

7 Pérez-Marco, A., Soares, P., Davó-Blanes, M. C., & Vives-Cases, C. (2020). Identifying Types of Dating Violence and Protective Factors among Adolescents in Spain: A Qualitative Analysis of Lights4Violence Materials. International journal of environmental research and public health, 17(7), 2443. https://doi.org/10.3390/ijerph17072443

8 Ibid.

9 Polanti et al. (2023)

10 Malik, M., Munir, N., Ghani, M. U., & Ahmad, N. (2021). Domestic violence and its relationship with depression, anxiety and quality of life: A hidden dilemma of Pakistani women. Pakistan journal of medical sciences, 37(1), 191–194. https://doi.org/10.12669/pjms.37.1.2893

11 Ibid.

12 Telloian, C. (2023, March 23). What Are the Effects of Emotional Abuse? https://psychcentral.com/health/effects-of-emotional-abuse#relationship-impacts 

13 PTSDuk. (2023). Causes of PTSD: Domestic Abuse. https://www.ptsduk.org/what-is-ptsd/causes-of-ptsd/domestic-abuse/

14 Ibid.

15 De Sousa, D., Paradis, A., Fernet, M., Couture, S., & Fortin, A. (2023). "I felt imprisoned": A qualitative exploration of controlling behaviors in adolescent and emerging adult dating relationships. Journal of adolescence, 95(5), 907–921. https://doi.org/10.1002/jad.12163

16 Guy, S. (2020, October 19). When Love is Blind: What Teens Don’t See in an Abusive Relationship. https://www.genesisshelter.org/when-love-is-blind-what-teens-dont-see-in-an-abusive-relationship/

17 Cleveland Clinic. (2022, February 14). Stockholm Syndrome. https://my.clevelandclinic.org/health/diseases/22387-stockholm-syndrome

18 Karakurt, G., Koç, E., Katta, P., Jones, N., & Bolen, S. D. (2022). Treatments for Female Victims of Intimate Partner Violence: Systematic Review and Meta-Analysis. Frontiers in psychology, 13, 793021. https://doi.org/10.3389/fpsyg.2022.793021

19 Ibid.

20 Pérez-Marco, et al. (2020)

21 Oğuztüzün, Ç., Koyutürk, M., & Karakurt, G. (2023). Characterizing Disparities in the Treatment of Intimate Partner Violence. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science, 2023, 408–417. 

22 Wexler D. B. (1999). The broken mirror. A self psychological treatment perspective for relationship violence. The Journal of psychotherapy practice and research, 8(2), 129–141. 

The Role of Gratitude in Improving Mental Health

Focusing on the Good 

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

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

The origins of gratitude 

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

Evolutionary: 

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

Neurobiological: 

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

Factors that contribute to gratitude

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

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

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

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

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

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

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

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

Individual Benefits 

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

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

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

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

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

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

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

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

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

Social Benefits

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

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

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

Gratitude interventions 

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

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

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

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

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

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

Contributed by: Kaylin Ong

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

References

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

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

3 APA (2015) 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

20 Ibid. 

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

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

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

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

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

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

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

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

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

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

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

32 Allen (2018) 

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

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

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

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

Examining Cross-Cultural Differences in Mental Health Diagnoses

Does Location Matter?   

Why do certain psychiatric conditions share universal diagnosis criteria and treatment while others vary widely, dependent on location and culture? These discrepancies can be attributed to the lack of a gold standard for validating these conditions as well as the lack of biological markers, leading to different clinical interpretations and inconsistency across studies.[1]

Consistency across cultural studies can allow a more general understanding of conditions and how culture affects symptoms’ manifestations and diagnoses differently. By creating a clearer understanding of mental health conditions worldwide, better/more effective treatments and patient outcomes can arise. 

Should Diagnosis be Universal or Relative?   

Within the debate of why these differences occur, two main arguments exist. The first focuses on universality across cultures. The “universalistic viewpoint” emphasizes that all conditions occur equally and have a core set of symptoms - what varies is the manifestations and determination of pathology versus normalcy. “Ethnotypic consistency” was coined by Weisz et al., in 1997 to describe the idea that psychopathology is the same across locations and cultures, but varies in how symptoms are displayed.[2]  

The opposing viewpoint of universality places a larger emphasis on culture. The “relativistic viewpoint” stresses that culture shapes a person’s development and psychopathology. Symptoms and conditions can be unique and particular to specific cultures, as well as affect the magnitude and intensity of the condition.[3] 

From these two viewpoints, a combined conclusion can be established: certain disorders are seen as “universally occurring” due to their neural pathology, while others are shaped by social contexts and cultural norms.[4] 

Examining Cross-Cultural Differences 

One of the most well-researched conditions cross-culturally is attention-deficit/hyperactivity disorder (ADHD). From 1997 to 2016, attention deficit disorders in the United States has fluctuated from 6.1% to 10.2%, with debate ensuing whether the fluctuation arose from over-diagnosis, under-diagnosis and/or diagnostic disparities.[5] When comparing global prevalence, vast differences were found between North America, Africa and the Middle East. However, those differences were not found between North America, Europe, Oceania, Asia or South America. Canino and Alegria (2008) note that these discrepancies were attributed to the differences in instruments, methods, and how these disorders are defined within the different cultural studies compared.[6] 

Professor Mashai Ikeda began to research Bipolar Disorder (BD) after finding most conclusions on major psychiatric disorders were made using European samples. In 2022, Ikeda specifically looked at the genes of patients with BD type I (manic and depressive states) and BD type II (mild mania and depression) between European populations and East Asian populations.[7] He found East Asian populations containing genes of BD I were more correlated with major depression while European populations with BD I were more correlated with schizophrenia, however, no differences were found between the samples when examining BD type II. These differences were attributed to how the disorder is diagnosed in each country; East Asian psychiatrists hold that bipolar disorder is a mood disorder while European psychiatrists tend to diagnose patients with delusion and other psychotic symptoms.[8] These vast differences in definitions can later lead to issues with clinical trials, especially for drug therapy. 

Even the threshold that needed to be met to be considered pathological differs culturally. For example, Hong Kong’s rates of reported hyperactivity are double those of the United States.[9] Additionally, Chinese and Thai cultures place a high value on hiding aggression and overt behaviors, which lowers the threshold of hyperactive behaviors and raises the likelihood that parents would report it. Chinese and Indonesian clinicians also gave higher scores for hyperactive behavior problems when compared to scores given by Japanese and American clinicians.[10] A study conducted by Bird (2002) examined Italy, New Zealand, China, Germany, Brazil and Puerto Rico and found that hyperactive disorders were found in all cultures, but the prevalence and threshold of what was considered pathological is what differed. Therefore, while these conditions happen universally, the way each culture views the symptoms varies widely.[11]

These cultural distinctions of appropriateness not only occur cross-continentally but also within different communities. According to Andrade (2017), African Americans are more likely than White Americans to keep personal distress private and seek spiritual support versus seeking professional mental health treatment.[12] Further, in the United States, most minority groups are less likely than White Americans to seek mental health treatments or delay seeking help until their symptoms are severe. Many of these issues are tied to the discrimination and mistreatment minorities face when seeking help; in fact, 43% of African Americans and 28% of Latinos have felt they were mistreated in clinical settings due to their background.[13] There is also a lack of resources for non-English speakers to gain access to mental health services. These cultural factors tied with affordability and insurance coverage also create a very difficult situation for many people in certain populations to get mental health assistance at all. 

Mental health resources vary widely across the globe, depending on location. Nielsen, et al., (2022) found major differences among countries in the Far East, Middle East, and Southeast Europe, as most countries reported the need for more child psychiatrists and mental health professionals. The researchers note that 10% to 20% of adolescents experience a mental health disorder before they turn 14 years old.[14] Thus, the lack of resources in these countries poses a great risk to the population, as early intervention is key to recovery and well-being.

Future Steps: Integrating Culture and Diagnosis 

These locational and cultural challenges pose a clear threat to the reliability and validity of cross-cultural research; as we discover more about how these factors affect diagnosis and symptoms, it is essential to create instruments keeping these differences in mind. Historically, research has been based on Western diagnosis systems and definitions, but when using those definitions with other populations, concepts can become unclear.[15] Conceptual equivalence ensures the concept is identified uniformly according to the populations being studied.[16] Therefore, these disparities must be emphasized when conducting research. If not, misclassifications and incorrect conclusions about populations can be made. 

Harris (2023) stresses that with the growing importance culture plays on manifestations and diagnosis, it is important clinicians and mental healthcare professionals assess how a person’s background affects their condition. As well, adjust their assessment based on the person’s attitude towards mental health and how they express and cope with their mental health. Different populations may also have stigmas on seeking help or undergoing certain treatments, professionals must be aware of and protect those preferences.[17] 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has also embraced these strategies and highlights the impact of race and culture on disorders. Clarifications and disclaimers have been added to provide further information when specific communities had higher rates of certain disorders.[18] These considerations are fundamental in improving the disparities in diagnosis found across cultures as it allows psychiatry residents and fellows to see the effects race and culture can have on mental health and diagnosis.  

If you or someone you know is struggling with their mental health, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

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

1 Canino, G., & Alegría, M. (2008). Psychiatric diagnosis – is it universal or relative to culture? Journal of Child Psychology & Psychiatry, 49(3), 237–250. https://doi.org/10.1111/j.1469-7610.2007.01854.x

2 Ibid. 

3 Ibid. 

4 Ibid. 

5 Abdelnour, E. (2022, October 1). ADHD diagnostic trends: Increased recognition or overdiagnosis? PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/#:~:text=The%20past%20couple%20of%20decades,the%20causes%20for%20this%20trend 

6 Canino & Alegría (2008)

7 Saito, T., Ikeda, M., Terao, C., Ashizawa, T., Miyata, M., Tanaka, S., Kanazawa, T., Kato, T., Kishi, T., & Iwata, N. (2022). Differential genetic correlations across major psychiatric disorders between Eastern and Western countries. Psychiatry and Clinical Neurosciences, 77(2), 118–119. https://doi.org/10.1111/pcn.13498 

8 Ibid. 

9  Ho, T.P., Leung, P.W., Luk, E.S., Taylor, E., BaconShone, J., & Mak, F.L. (1996). Establishing the constructs of childhood behavioral disturbances in a Chinese population: A questionnaire study. Journal of Abnormal Child Psychology, 24, 417–4314

10 Canino & Alegría (2008)

11 Bird, H. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of ADHD. In P.S. Jensen & J. Cooper (Eds.), Attention deficit hyperactivity disorder: State of the science; best practices (pp. 12-1–12-36). Kingston, NJ: Civic Research Institute. 

12 Andrade, S. (2017). Cultural Influences on Mental Health | The Public Health Advocate. The Public Health Advocate. 

https://pha.berkeley.edu/2017/04/16/cultural-influences-on-mental-health/

13 Ibid. 

14 Nielsen, M. S., Clausen, C. E., Hirota, T., Kumperscak, H., Guerrero, A., Kaneko, H., & Skokauskas, N. (2022). A comparison of child and adolescent psychiatry in the Far East, the Middle East, and Southeast Europe. Asia-Pacific Psychiatry, 14(2), 1–9. 

https://doi.org/10.1111/appy.12490

15 Canino & Alegría (2008)

16 Ibid. 

17 Harris, J. (2023, January 9). Cultural competency in mental Health Care: Why it matters. NAMI - Dominate Amazing Capabilities. https://nami-dac.org/cultural-competency-in-mental-health-care-why-it-matters/

18 Moran, M. (2022). Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR. Psychiatric News, 57(3).  https://doi.org/10.1176/appi.pn.2022.03.3.20

Exploring The Psychological Impacts of Pornography

Porn: The Widespread Taboo

Pornography is the most available it has ever been due to online accessibility. Consequently, the more views that pornography accumulates, the increasing amount of societal and psychological consequences people face. This includes, but is not limited to: stereotyping of gender and racial fetishes, sexual violence and misconduct, sex misinformation, content addiction, and sex worker stigmas. Solano et al. (2020) found that among a sample of 1,392 adults in the U.S. (ages 18 to 73), 91.5% of men and 60.2% of women reported that they had engaged in some type of pornography within the past month.[1] Exposure to sexual content seems to be a frequent and inevitable component of being connected to the internet. However, a wave of sexual health research indicates its usage is not inherently negative. Discussions surrounding the psychological impacts of pornography provide insights into how porn can be distributed in healthy ways while also reducing negative consequences. Understanding this research is pivotal in approaching mental health and its relationship with pornography in an exponentially growing online world.

Understanding Pornography

Pornography exists in a variety of forms ranging from written, still imagery, video and auditory content. The Merriam-Webster Dictionary defines pornography as the depiction of erotica for sexual enhancement or excitement.[2] Free online platforms invite higher usage of video content than other forms of porn.[3] Additionally, Solano et al. (2020) found that women are more likely to consume written porn than men.[4] Reasons for pornography usage were researched by Burtăverde et al. (2021), who found that many people seek content for short-term sexual enjoyment and masturbation.[5] Likely due to its increased availability, pornography viewership is also beginning at younger ages; among responses from university students, Biota et al. (2022) found that porn usage began at an average age of 10.4 years, with those partaking primarily out of curiosity.[6] Further, as many students from this study reported feeling that their sex education has been inadequate, this perceived lack of education has likely led to their increased search for sexual information online, through porn.[7] 

Opinions about users of porn, as well as actors, vary by culture and social norms. Societal attitudes about the motivations behind pornographers were studied by Evans-DeCicco & Cowan (2001) in which male performers were perceived as having more positive motivations for partaking in porn production (such as enjoying their work and being at the top of their profession) as opposed to female performers.[8] Female performers were more often than men perceived/stereotyped to come from dysfunctional families, have a lack of employment opportunities and be coerced into the work.[9] Additionally, Perry & Whitehead (2022) point out that in the U.S., the desire for anti-pornography legislation is predicted by Christain nationalism and strict values of sexual order.[10] 

The Neuroscience of Pornography & Addiction

Pornography addiction is not considered a DSM-5 categorized disorder, however, concern exists about the adverse effects of over-watching porn. For instance, Egan & Parmar (2013) note that online porn usage can be reflective of compulsive tendencies in men.[11] Market et al. (2021) also found that for men with higher sexual motivation, attention to pornographic pictures was enhanced but that there were also no connections made with symptoms of cybersex addiction.[12] A study done by Wang et al. (2022) likewise found that people with problematic internet pornography use display higher attention and brain responses to new sexual stimuli, maintaining a cycle of problematic porn consumption when they are presented with more porn.[13] Further, Biota et al. (2022) found that the self-perceived negative effects of pornography use were mainly decreased sexual satisfaction and the need for more stimuli and longer stimulation, suggesting possible reasons for cyclical tendencies.[14]

Behavioral addictions in the brain impair reward systems through the frontal lobes via hyprofrontal syndromes (i.e., cerebral dysfunctions of addiction) leading to compulsivity and flawed judgment;[15] substance abuse, internet gaming disorder, compulsive eating and trauma may change the brain in the same way.[16] More research is warranted for problematic hypersexual tendencies and pornography use, as its general consumption may be completely healthy, while its over-usage may be indicative of compulsive tendencies.

Psychological Effects of Pornography

The sheer variety of porn produced has resulted in a range of negative and positive psychological effects on viewers, reflected in several conflicting pieces of evidence in the research. Since 2016, 17 states have introduced nonbinding resolutions declaring pornography a public health crisis, with concerns ranging from infidelity, addiction and sex trafficking.[17] Conversely, Nelson & Rothman (2020) report that porn, itself, does not meet the criteria for a public health crisis and that it has also been found to increase feelings of acceptance and health-promoting behaviors such as increased intimacy, communication and safer sexual practice.[18]

However, other researchers have found negative psychological and behavioral associations with pornography. In examining the link between porn and body image, Gewirtz-Meydan & Spivak-Lavi (2023) found that increased porn usage related to more body comparisons being made as well as an increase in eating disorder symptoms in men.[19] Additionally, Rostad et al. found that porn exposure is associated with teen dating violence and aggression (with a higher effect in boys than girls),[20] and Kohut, & Štulhofer (2018) note that porn use is associated with low adult quality of life.[21] 

These associations, however, do not imply a causal relationship with porn. Such consideration may be informative of the demographics of porn users, as porn may be used to improve or satisfy already-impaired psychological states.[22] Kohut, & Štulhofer add that controlling for external factors in an individual’s life (such as family environment and impulsiveness) may help us understand what porn actually does to our mental health.[23] While Mollaioli et al. (2021) found that more sexual activity is generally related to better mental health with lower participant depression and anxiety scores,[24] one must be aware that viewing certain portrayals in porn (e.g., flawless body image, condomless sex and violent fetishization), as well as a user’s dispositions may actually result in adverse effects. 

Relationship Function & Dysfunction

Kohut et al., (2021) investigated the notion that pornography use leads to poor relationship quality and satisfaction and found that differences in partner sex drive is what actually accounts for discrepancies in relationship quality.[25] Differences in sex drive can lead to differences in porn usage among partners, which leads to varied perceptions of the relationship and each person’s sexual satisfaction.[26] Further, when respondents were generally less accepting of porn, more porn usage led to lower perceived relationship satisfaction - but when men were more accepting of porn, they indicated higher relationship satisfaction.[27] These findings provide insight into the effects of the meaning that one places on using pornography, and how the stigmatization of its usage infiltrates itself into relationships.

Addressing The Issues

While the topic of sex and pornography is incredibly taboo in most cultures, increased dialogue surrounding the effects of pornography is important to promote mental health and safe porn use. Porn that portrays harmful aspects of society like nonconsent (i.e., assault) is damaging, such as instances where porn is leaked or promoted without the consent of the people involved.[28] Gius (2022) notes these leaks are societally perceived as extremely negative due to sexism and gender inequality, leading to social pressure on the assaulted/exposed individuals and even suicide.[29] 

Hilton & Watts (2011) add that some people argue for all porn usage to be viewed from a public health lens due to factors ranging from stigmatization of sex to addiction research.[30] Others believe that explicit sexual content is inevitable and that while compulsive use can be targeted with treatment, outlawing porn will not alter its use. Reducing life-impairing over-usage of pornography may be achieved through psychotherapeutic methods and Camilleri et al. (2021) found that morals, faith, and individual motivation were the most effective factors in reducing porn use.[31] Historically, since anti-sex views have not taken away sex from people, approaching porn in an open and informed way may help younger generations form healthy practices. 

For adolescents, sex education regarding healthy, consensual sex may help to reduce the harmful effects of mainstream porn content. Consuming online porn is among the many factors for intimate partner violence among young people.[32] Pathmedra et al. (2023) note that adolescent exposure to sexual content has a large role in establishing healthy sexual and romantic relationships - but acknowledge that it also has a role in establishing unhealthy relationships.[33] A conscientious approach to the way that porn is produced would be beneficial regarding the stereotypes and values it projects to its audiences.[34]

Overall, pornography usage is self-perceived as positive among both adolescents[35] and adults.[36] Additionally, an increased amount of people are participating in generating pornography through online platforms (such as OnlyFans), where they can personally capitalize off of content creation more lucratively than many professional productions and mainstream career paths. Further, Toder & Barak-Brandes (2022) examined homosexual WhatsApp exchanges for profit and discussed how it grants users sexual freedom, escaping from paths of porn careers that promote unethical sex.[37] 

Sexual openness and literacy may help to reduce the negative effects of pornography. Biota et al. (2022) stress that since people tend to consume porn at early ages, sex education needs to be tailored so that people can have a normalized understanding of porn and what is healthy.[38] Further, this education may aid in helping people identify what is unethical and ethical in portrayals of sex so that rape culture and violence are not perpetuated by porn. Regarding problematic or compulsive porn usage, Testa et al. (2023) note that promoting media literacy is an effective strategy to use in order to develop greater critical thinking skills, reduce the shame associated with porn, recognize unrealistic productions of sex and interpret the meaning behind what is being viewed, thereby creating healthier choices. In addition, cognitive behavioral therapy (CBT) and mindfulness-based therapies are evidence-based modalities that can help with compulsive porn usage.[39] Many different factors combine to create the negative mental health and societal effects of porn, and these may be generally addressed through open and updated sex perspectives, in addition to conscientiousness surrounding porn production and distribution. 

If one is experiencing problematic pornography consumption that impairs well-being, relationships and/or daily life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

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

References

1 Solano, I., Eaton, N. R., & O'Leary, K. D. (2020). Pornography Consumption, Modality and Function in a Large Internet Sample. Journal of sex research, 57(1), 92–103. https://doi.org/10.1080/00224499.2018.1532488 

2 Merriam-Webster. (n.d.). Pornography. In Merriam-Webster.com dictionary. Retrieved July 3, 2023, from https://www.merriam-webster.com/dictionary/pornography 

3 Ibid.

4 Ibid.

5 Burtăverde, V., Jonason, P. K., Giosan, C., & Ene, C. (2021). Why Do People Watch Porn? An Evolutionary Perspective on the Reasons for Pornography Consumption. Evolutionary Psychology, 19(2). https://doi.org/10.1177/14747049211028798

6 Biota, I., Dosil-Santamaria, M., Mondragon, N.I., Ozamiz-Etxebarria, N. (2022). Analyzing University Students' Perceptions Regarding Mainstream Pornography and Its Link to SDG5. Int J Environ Res Public Health. Jun 30;19(13):8055. doi: 10.3390/ijerph19138055. PMID: 35805712; PMCID: PMC9265877.

7 Ibid. 

8 Evans-DeCicco, Jennee & Cowan, Gloria. (2001). Attitudes Toward Pornography and the Characteristics Attributed to Pornography Actors. Sex Roles. 44. 351-361. 10.1023/A:1010985817751.  

9 Ibid.

10 Perry, S. L., & Whitehead, A. L. (2022). Porn as a threat to the mythic social order: Christian nationalism, anti-pornography legislation, and fear of pornography as a public menace. Sociological Quarterly, 63(2), 316-336. doi:10.1080/00380253.2020.1822220 

11 Egan, V., & Parmar, R. (2013). Dirty habits? Online pornography use, personality, obsessionality, and compulsivity. Journal of sex & marital therapy, 39(5), 394–409. https://doi.org/10.1080/0092623X.2012.710182

12 Markert, C., Baranowski, A. M., Koch, S., Stark, R., & Strahler, J. (2021). The impact of negative mood on event-related potentials when viewing pornographic pictures. Frontiers in Psychology, 12 doi:10.3389/fpsyg.2021.673023

13 Wang, J., Chen, Y., & Zhang, H. (2022). Electrophysiological evidence of enhanced processing of novel pornographic images in individuals with tendencies toward problematic internet pornography use. Frontiers in Human Neuroscience, 16 doi:10.3389/fnhum.2022.897536 

14 Biota et al. (2022)

15 Hilton DL, Watts C. Pornography addiction: A neuroscience perspective. Surg Neurol Int. 2011 Feb 21;2:19. doi: 10.4103/2152-7806.76977. PMID: 21427788; PMCID: PMC3050060.

16 Ibid.

17 Nelson, K. M., & Rothman, E. F. (2020). Should Public Health Professionals Consider Pornography a Public Health Crisis?. American journal of public health, 110(2), 151–153. https://doi.org/10.2105/AJPH.2019.305498

18 Ibid.

19 Gewirtz-Meydan, A., & Spivak-Lavi, Z. (2023). The association between problematic pornography use and eating disorder symptoms among heterosexual and sexual minority men. Body Image, 45, 284-295. doi:10.1016/j.bodyim.2023.03.008

20 Rostad et al. (2019)

21 Kohut, T., & Štulhofer, A. (2018). Is pornography use a risk for adolescent well-being? An examination of temporal relationships in two independent panel samples. PloS one, 13(8), e0202048. https://doi.org/10.1371/journal.pone.0202048 

22 Ibid.

23 Ibid.

24 Mollaioli, D., Sansone, A., Ciocca, G., Limoncin, E., Colonnello, E., Di Lorenzo, G., & Jannini, E. A. (2021). Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout. The journal of sexual medicine, 18(1), 35–49. https://doi.org/10.1016/j.jsxm.2020.10.008

25 Kohut, T., Dobson, K. A., Balzarini, R. N., Rogge, R. D., Shaw, A. M., McNulty, J. K., Russell, V. M., Fisher, W. A., & Campbell, L. (2021). But What's Your Partner Up to? Associations Between Relationship Quality and Pornography Use Depend on Contextual Patterns of Use Within the Couple. Frontiers in psychology, 12, 661347. https://doi.org/10.3389/fpsyg.2021.661347 

26 Ibid.

27 Maas, M. K., Vasilenko, S. A., & Willoughby, B. J. (2018). A Dyadic Approach to Pornography Use and Relationship Satisfaction Among Heterosexual Couples: The Role of Pornography Acceptance and Anxious Attachment. Journal of sex research, 55(6), 772–782. https://doi.org/10.1080/00224499.2018.1440281

28 Gius, C. (2022). Addressing the blurred question of ‘responsibility’: Insights from online news comments on a case of nonconsensual pornography. Journal of Gender Studies, 31(2), 193-203. doi:10.1080/09589236.2021.1892610 

29 Ibid.

30 Hilton & Watts (2011)

31 Camilleri, C., Perry, J. T., & Sammut, S. (2021). Compulsive Internet Pornography Use and Mental Health: A Cross-Sectional Study in a Sample of University Students in the United States. Frontiers in Psychology, 11, Article 613244. https://doi.org/10.3389/fpsyg.2020.613244

32 Barter, C., Lanau, A., Stanley, N., Aghtaie, N., & Överlien, C. (2022). Factors associated with the perpetration of interpersonal violence and abuse in young people’s intimate relationships. Journal of Youth Studies, 25(5), 547-563. doi:10.1080/13676261.2021.1910223

33 Pathmendra, P., Raggatt, M., Lim, M. S. C., Marino, J. L., & Skinner, S. R. (2023). Exposure to pornography and adolescent sexual behavior: Systematic review. Journal of Medical Internet Research, 25 doi:10.2196/43116

34 Ibid. 

35 Dwulit, A. D., & Rzymski, P. (2019). Prevalence, Patterns and Self-Perceived Effects of Pornography Consumption in Polish University Students: A Cross-Sectional Study. International journal of environmental research and public health, 16(10), 1861. https://doi.org/10.3390/ijerph16101861

36 Hald, G.M., Malamuth, N.M. Self-Perceived Effects of Pornography Consumption. Arch Sex Behav 37, 614–625 (2008). https://doi.org/10.1007/s10508-007-9212-1

37 Toder, N., & Barak-Brandes, S. (2022). A booty of booties: Men accumulating capital by homosocial porn exchange on WhatsApp. Porn Studies, 9(2), 145-158. doi:10.1080/23268743.2021.1947880  

38 Biota et al. (2022)

39 Testa, G., Mestre-Bach, G., Chiclana Actis, C., & Potenza, M. N. (2023). Problematic pornography use in adolescents: From prevention to intervention. Current Addiction Reports, 10(2), 210-218. doi:10.1007/s40429-023-00469-4  

Schizophrenia: Cross-Cultural Comparisons of Case Management & Research Progress

A Global Enigma

While our understanding of the human brain is constantly advancing, one of the least understood psychological disorders with the most ubiquitous global impact, is schizophrenia. Schizophrenia is a chronic mental illness characterized by symptoms generally falling into three categories:[1,2] 

• Psychotic Symptoms: Hallucinations, delusions, disorganized speech and behaviors

• Negative Symptoms: Withdrawal from aspects of life, difficulty functioning normally, affective flattening, lack of motivations

• Cognitive Impairment: Problems in attention, concentration and memory. 

The prevalence of the disease is approximately 1% worldwide and accounts for a large healthcare burden. It is highly heritable (e.g., the likelihood of the disorder to aggregate among family members), estimated at around 80%.[3] Further, Degnan et al. (2018) note that the incidence rate of schizophrenia in ethnic minority populations are triple that of major White populations.[4] 

In itself, the definition and categorization throughout the history of schizophrenia has differentiated across countries. Schizophrenia was first described by Emil Kraepelin (1899), a German psychiatrist, as “attentional impairments”.[5] Eugen Bleuler (1911) later famously coined it as a disorder which originates from the splitting of different psychic functions leading to loss of unity within the personality (hence the name “schizophrenia”) from the Greek roots “split-mind.”[6] Our foundational understanding of the disease is still limited, and this article aims to review some current cross-cultural perspectives on the research and management of the disease.

The diverse faces of psychosis in schizophrenia  

Recent research has consolidated the literature on the effects of cultural and social perspectives on the framing of schizophrenic/psychotic symptoms. While psychosis is present globally as a symptom for schizophrenia, the actual content of the psychotic symptom is culturally determined.[7] For example, research conducted in India, Nigeria and Trinidad in 2016  concluded that “disruptive behaviors, wandering and decline in functioning” are more commonly thought of as psychosis rather than the “distorted perceptions and beliefs” emphasized in Western understanding of the condition.[8] 

Additionally, the interpretations of psychiatrists determine what behaviors constitute psychosis; this, too, will vary based on one’s training, education, upbringing and life experiences, which differ across cultures.[9] In a case study in 2008, a NHS psychiatric nurse in a London hospital recounted his conflict for a Nigerian patient diagnosed with schizophrenia under his care. While in Nigeria, the patient’s “psychotic symptom” of religious delusions would have been considered gifted, the patient was coerced into taking medication in the UK.[10] Therefore, it is important to consider cultural backgrounds as a crucial factor in determining the symptoms of the disease. 

Cross-national context and culturally-adapted interventions of schizophrenia

Schizophrenia has been identified as a globally-prioritized mental health problem with the magnitude of its impact on individuals’ health, economic and social hardships, increased mortality rates and human rights violation (e.g., involuntary hospitalization or imprisonment with inadequate mental health care).[11,12] Recommendations from the World Health Organization (WHO) guidelines and the Disease Control Priorities (DCP3)  have shown that there are two kinds of intervention for schizophrenia that have strong enough evidence to deem them significant: antipsychotic drugs and psychosocial treatments.[13] However, one important limitation is that there is little evidence supporting these interventions in low and middle income countries (LMIC), and few of them have been actually implemented in high income countries.[14]

Psychosocial Interventions:

The psychosocial treatments of schizophrenia with strongest empirical support are: social skills training; family psychoeducation; cognitive behavioral therapy (CBT) and cognitive rehabilitation.[15,16] 

In 2012, Lora et al. noted that among 50 LMICs, around 69% of those diagnosed with schizophrenic disorders do not have access to specialized care despite evidence that psychosocial interventions alone can alleviate symptoms of the disorder, and not all patients may require treatment with antipsychotics.[17,18] In 2018, Degnan et al. published a review on adaptations of Western psychosocial interventions to specific ethnic groups or subculture studying these adaptations in 13 different countries.[19] It was found that all cultural adaptations included language, a majority adapted to concepts and illness models, cultural norms and practices, and family. Noticeably, there were modifications to include spiritual/religious activities, adjustments to communication styles and family dynamics. The analysis demonstrated significant outcomes in support of adapted interventions, however only two studies out of 43 compared the effectiveness of adapted and non-adapted interventions, and neither found significant differences in outcomes.[20] Overall, while the study indicates positive results for culturally-adapted psychosocial interventions, the limited studies providing support for adapted over non-adapted treatments is not enough evidence of a significant increase in effectiveness.

Antipsychotic Interventions: 

While psychosocial interventions have been increasingly researched and recognized as effective care for schizophrenia, antipsychotics have long been the popular measure of intervention for medical professionals.[21] Common antipsychotic agents are classified as first-generation (chlorpromazine, haloperidol) or second-generation (clozapine), which work by blocking dopamine receptors.[22] According to Wood et al. (2003), first-generation drugs are more-likely to induce parkinsonian side effects and second-generation drugs are thought to have enhanced therapeutic efficacy.[23] However, research by Agid et al. (2006) questions if the side effects of first-generation schizophrenia drugs may actually be from unintentionally overdosing patients while searching for optimal drug efficacy (hence, inadvertently causing more-pronounced side effects).[24] 

Recent research on culturally-adapted antipsychotics and alternative drug treatments for schizophrenia has been scarce. However, a study done by Chong et al. (2004) on differences in antipsychotics usage in East Asian countries revealed that prescription patterns of antipsychotic drugs vary greatly between countries.[25] This can be explained by the differences in respective healthcare policies, preferred treatment modality, availability and cost of the drugs.[26]

For example, Japan has a long history of national health insurance and a preference for treating patients with mental health issues in psychiatric hospitals over community care. Therefore, a higher prevalence of antipsychotics is prescribed due to the longer hospitalization period for schizophrenia in the country.[27] Meanwhile, Xiang et al. (2017) also found that while community-based services are increasingly encouraged, a large number of patients in China end up receiving hospital-based services.[28] Additionally, as clozapine is the most effective and affordable antipsychotic medication in China, over one-third of schizophrenia patients have been prescribed the drug.[29] This is not the case for all countries in the surrounding regions, as the cost of second-generation antipsychotic is considerably higher, thus is often restricted and difficult to prescribe.[30] However, as first-generation antipsychotics for schizophrenia are known as “major tranquilizers” with more serious side effects, this may create a disparity in treatment of the disorder in different countries.[31] 

Alternative treatments may also prove valuable. In 2017, a study conducted by Deng et al. on Wendan decoction (WDD), a traditional Chinese medicine for schizophrenia, discovered that WDD demonstrated some short-term positive effects on its own. Further, when WDD was used alongside an antipsychotic, positive outcomes were observed with fewer adverse effects.[32] 

Future directions: beyond the “one-size-fits-all” treatment framework

While there is still more research to be done, this brings the question to whether popular antipsychotics are the ultimate pharmacological treatment for schizophrenia, or if there are alternative options we need to take into consideration. Specialists have long called for the facilitation of mental health care by traditional practitioners due to lack of resources in LMICs; research has echoed the sentiment that traditional healers are generally more accessible and affordable, and patients benefit from sharing cultural beliefs and world views with them.[33] 

Traditional healers have often been more open to collaborating with primary health care than vice versa.[34] Watt et al. (2017) studied this issue qualitatively with populations in Ghana, Kenya and Nigeria. They found that many patients and caregivers still distrust non-medical treatments; despite some medical practitioners advocating for their validity, traditional care is often met with ridicule and doubt. The study further found that there appear to be suggestions to “convert” non-medical healers to a medical paradigm, and that rivalry and perceived superiority seem to be the underlying cause of this attitude.[35] 

However, it is also important to note that patients who implore both methods of care seem to reap more benefits, overall.[36,37] Watt et al. note that non-medical healers also desire to be recognized in their validity and not be exoticized simply due to their non-Western practices and beliefs.[38] Many studies have supported that labeling these practices as “witchcraft” or “inferior” is failing to understand indigenous knowledge and meaningful perspectives, and thus a missed opportunity to improve population health.[39,40]

Social and cultural perspectives continue to inform the characteristics and future directions of both the research and treatment of schizophrenia. Yet, as we have seen, the current landscape of what we know about the disorder in a cross-cultural context is lacking. As we expand on this field of research in a broader context, it is important to note the potentials of alternative medicine, culturally-adapted measures and how they can benefit the accessibility of health care for ethnic minorities, non-Western or low/middle-income patients. Acknowledgement and deeper insight into culturally-appropriate diagnosis and care for patients with schizophrenia is crucial to shift the evolution of global mental health into a truly global discipline. 

If you or someone you know are experiencing any signs of schizophrenia, it’s best to speak with a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss your concerns and determine the underlying cause of symptoms.

Contributed by: Mai Tran

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

References

1 Rahman, T., & Lauriello, J. (2016). Schizophrenia: An Overview. Focus (American Psychiatric Publishing), 14(3), 300–307. https://doi.org/10.1176/appi.focus.20160006

2 NHS. (2023, April 13). Symptoms - Schizophrenia. NHS. https://www.nhs.uk/mental-health/conditions/schizophrenia/symptoms/ 

3 McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA Psychiatry. 2020;77(2):201–210. doi:10.1001/jamapsychiatry.2019.3360  

4 Degnan, A., Baker, S., Edge, D., Nottidge, W., Noke, M., Press, C. J., Husain, N., Rathod, S., & Drake, R. J. (2018). The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis. Psychological Medicine, 48(5), 714–727. https://doi.org/10.1017/S0033291717002264

5 Kraeplin, E. (1950). Dementia praecox and paraphrenia (J. Zinkin, Trans.).

6 Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press. 

7 Shalhoub, H. (2012). Decoding schizophrenia across cultures: Clinical, epidemiological and aetiological issues (Doctoral dissertation, School of Social Sciences Theses).

8 Cohen, Alex; Padmavati, Ramachandran; Hibben, Maia; Oyewusi, Samuel; John, Sujit; Esan, Oluyomi; Patel, Vikram; Weiss, Helen; Murray, Robin; Hutchinson, Gerard; Gureje, Oye; Thara, Rangaswamy; Morgan, Craig (2016). Concepts of madness in diverse settings: a qualitative study from the INTREPID project. BMC Psychiatry, 16(1), 388–. doi:10.1186/s12888-016-1090-4

9 Shalhoub (2012)

10 Ibid.

11 Wigand, M. E., Orzechowski, M., Nowak, M., Becker, T., & Steger, F. (2021). Schizophrenia, human rights and access to health care: A systematic search and review of judgements by the European Court of Human Rights. The International Journal of Social Psychiatry, 67(2), 168–174. https://doi.org/10.1177/0020764020942797

12 Patel V. (2016). Universal Health Coverage for Schizophrenia: A Global Mental Health Priority. Schizophrenia Bulletin, 42(4), 885–890. https://doi.org/10.1093/schbul/sbv107

13 Ibid. 

14 Ibid.

15 Alan. S. Bellack (2001) Psychosocial treatment in schizophrenia, Dialogues in Clinical Neuroscience, 3:2, 136-137, DOI: 10.31887/DCNS.2001.3.2/asbellack

16 Cooper, R. E., Laxhman, N., Crellin, N., Moncrieff, J., & Priebe, S. (2020). Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review. Schizophrenia Research, 225, 15–30. https://doi.org/10.1016/j.schres.2019.05.020

17 Ibid.

18 Lora, Antonio; Kohn, Robert; Levav, Itzhak; McBain, Ryan; Morris, Jodi; Saxena, Shekhar (2012). Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bulletin of the World Health Organization, 90(1), 47–54B. doi:10.2471/BLT.11.089284  

19 Degnan et al. (2018)

20 Ibid. 

21 Guo, Xiaofeng; Zhai, Jinguo; Liu, Zhening; Fang, Maosheng; Wang, Bo; Wang, Chuanyue; Hu, Bin; Sun, Xueli; Lv, Luxian; Lu, Zheng; Ma, Cui; He, Xiaolin; Guo, Tiansheng; Xie, Shiping; Wu, Renrong; Xue, Zhimin; Chen, Jindong; Twamley, Elizabeth W.; Jin, Hua; Zhao, Jingping (2010). Effect of Antipsychotic Medication Alone vs Combined With Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia. Archives of General Psychiatry, 67(9), 895–. doi:10.1001/archgenpsychiatry.2010.105 

22 Wood, Alastair J.J.; Freedman, Robert (2003). Schizophrenia. New England Journal of Medicine, 349(18), 1738–1749. doi:10.1056/NEJMra035458  

23 Ibid. 

24 Agid, O., Seeman, P., & Kapur, S. (2006). The “delayed onset” of antipsychotic action—An idea whose time has come and gone. Journal of Psychiatry & Neuroscience, 31(2), 93–100.

25 Chong, M. Y., Tan, C. H., Fujii, S., Yang, S. Y., Ungvari, G. S., Si, T., Chung, E. K., Sim, K., Tsang, H. Y., & Shinfuku, N. (2004). Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry and Clinical Neurosciences, 58(1), 61–67. https://doi.org/10.1111/j.1440-1819.2004.01194.x

26 Ibid.

27 Ibid.

28 Xiang, Y. T., Kato, T. A., Kishimoto, T., Ungvari, G. S., Chiu, H. F. K., Si, T. M., Yang, S. Y., Fujii, S., Ng, C. H., & Shinfuku, N. (2017). Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009). Asia-Pacific Psychiatry: official journal of the Pacific Rim College of Psychiatrists, 9(4), 10.1111/appy.12277. https://doi.org/10.1111/appy.12277

29 Ibid.

30 Chong et al. (2004)

31 Ibid.

32 Deng H, Xu J. Wendan decoction (Traditional Chinese medicine) for schizophrenia. Cochrane Database Syst Rev. 2017 Jun 28;6(6):CD012217. doi: 10.1002/14651858.CD012217.pub2. PMID: 28657646; PMCID: PMC6481906.

33 van der Watt, A. S. J., Nortje, G., Kola, L., Appiah-Poku, J., Othieno, C., Harris, B., Oladeji, B. D., Esan, O., Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O. (2017). Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qualitative Health Research, 27(14), 2177–2188. https://doi.org/10.1177/1049732317729342

34 Ibid.

35 Ibid.

36 Abbo C. (2011). Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global health action, 4, 10.3402/gha.v4i0.7117. https://doi.org/10.3402/gha.v4i0.7117

37 Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154–170. https://doi.org/10.1016/S2215-0366(15)00515-5

38 Watt et al. (2017)

39 Konadu, K. (2008) Medicine and Anthropology in Twentieth Century Africa: Akan Medicine and Encounters with (Medical) Anthropology. African Studies Quarterly, Vol. 10 (2&3).

40 Shaw, I., & Middleton, H. (2013). Approaches to “mental health” in low-income countries: A case study of Uganda. Mental Health Review Journal, 18, 204–213. doi:10.1108/MHRJ-07-2013-0025