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)

Inside Anorexia: Understanding the Mental & Physical Impacts

Anorexia’s Grip on the Mind & Body 

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

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

• An unrealistic perception of body image or weight

• Fear of becoming fat 

• Thin appearance 

• Frequently skipping meals 

• Irritability 

• Social withdrawal 

• Abnormal blood count 

• Dry and/or yellowing skin 

• Fatigue 

• Eroding teeth from vomiting 

• Excessive exercise 

• Frequently checking mirrors or reflections for perceived flaws  

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

Physiological Effects 

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

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

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

Neuropsychological Effects 

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

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

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

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

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

• Memory: verbal memory and nonverbal memory, working memory  

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

• Visuospatial Ability: spatial planning, visuospatial representation

• Speed of information processing

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

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

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

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

Treatment 

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

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

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

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

Future Steps

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

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

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

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

Contributed by: Ryann Thomson

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

References 

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

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

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

4 “Anorexia Nervosa” Mayo Clinic

5 Ibid. 

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

7 “Anorexia Nervosa” Mayo Clinic

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

9 National Eating Disorders Association. (2018)

10 Northwestern Medicine. (2016)

11 “Anorexia Nervosa” Mayo Clinic

12 National Eating Disorders Association (2018)

13 Ibid. 

14 “Anorexia Nervosa” Mayo Clinic

15 National Eating Disorders Association (2018)

16 Ibid. 

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

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

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

20 National Eating Disorders Association (2018)

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

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

23 Ibid.

24 Weider, et al., (2014)

25 Grau et al., (2019)

26 Stedal et al., (2021) 

27 Ibid. 

28 Ibid. 

29 Ibid. 

30 Zakzanis et al., (2010)

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

32 Grau et al., (2019)

33 Ibid. 

34 Zakzanis et al., (2010)

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

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

37 Muratore & Attia (2021)

38 Ibid. 

39 Ibid. 

40 Ibid. 

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

42 Weider et al., (2014)

43 Grau et al., (2019) 

44 Stedal et al., (2021) 

45 Ibid. 

Smoking & Struggling: Nicotine Dependence & Co-Morbid Psychiatric Illnesses

Addressing the Addiction

The 2021 National Survey on Drug Use and Health found that among individuals aged 12 and older in the United States, approximately 22.0% report using tobacco or nicotine vaping products in the last 30 days. Further, the 2022 Future Monitoring Survey found that among young people, approximately 8.7% of 8th graders, 15.1% of 10th graders, and 24.8% of 12th graders report using any form of nicotine in the past 30 days.[1] 

While the smoking rates among adults without chronic conditions are significantly reduced over years, the rates remain high among adults with psychiatric disorders.[2] Nicotine dependence especially affects individuals with underlying mental illnesses or cognitive impairments, at a rate of approximately 41% - twice the rate of which the CDC reports for the general population. Many nicotine-dependent individuals have comorbid psychiatric disorders, such as attention-deficit hyperactivity disorder (ADHD), anxiety disorders, and depression.[3]

Nicotine Dependence & Comorbid Psychiatric Disorders 

Smoking is the leading and most preventable cause of death in the United States, which is disproportionately affecting those with psychiatric disorders. By determining the prevalence of nicotine dependence and comorbid psychiatric disorders, smoking cessation efforts can be more focused upon those affected individuals.[4]

Miller (2005) conducted a representative sample study of U.S. adults, to investigate the connection between nicotine dependence and psychiatric disorders. A face-to-face interview conducted according to the DSM-IV interview schedule assessed the dependence on nicotine and the presence of a wide range of psychiatric disorders based on DSM-IV criteria. One of the criteria was whether they used nicotine to alleviate withdrawal symptoms of nicotine. This could be assessed based on four factors:[5]

1. Using nicotine upon waking

2. Using nicotine despite being restricted from its use (e.g., banned in certain locations, activities, events)

3. Using nicotine to avoid withdrawal symptoms

4. Waking up in the middle of the night to use nicotine

The study concluded that a significant correlation exists between individuals with a nicotine dependence and certain Axis I (e.g., alcohol and drug use disorders, major depression, dysthymia, mania, hypomania, panic disorder with and without agoraphobia, social phobia, specific phobia, and generalized anxiety disorder) and Axis II disorders (e.g., avoidant, dependent, obsessive-compulsive, histrionic, paranoid, schizoid, and antisocial PDs).[6] There was an especially strong association to disorders involving alcohol and other drug use, as well as mood disorders such as major depression, specific phobia, antisocial, and paranoid personality disorders.[7] 

Nicotine smoking has also been found that put individuals at an increased risk for suicide, biopolar disorder, and a dose-response relationship has been found between smoking and schizophrenia. In a two-sample Mendelian randomization study conducted by Yuan et. al (2020), the odds ratios of smoking initiation was higher for all seven psychiatric disorders included in the study than for no psychiatric disorder at all. The disorders and odds ratios include 1.96 for suicide attempts, 1.69 for post-traumatic stress disorder, 1.54 for schizophrenia, 1.41 for bipolar disorder, 1.38 for major depressive disorder, 1.20 for insomnia, and 1.17 for anxiety.[8]

The symptoms of ADHD are notably similar to withdrawal symptoms of nicotine. For example, such symptoms include deficits in sustained attention, response inhibition, and working memory. Pomerleau et. al (1995) found in their study that individuals with ADHD are at more risk for smoking due to the similarities in these symptoms, and the quit ratio for smokers with ADHD was 29%, while the quit ratio for smokers with no mental illness was a significantly higher percent of 48.5%. Other studies have also reached similar results, with Lambert and Hartsough (1998) finding tobacco dependence to be 40% in individuals with ADHD, compared to 19% for individuals without ADHD.[9] 

The reason why nicotine dependence affects patients with psychiatric disorders disproportionately higher is because people may attempt to self-medicate to alleviate symptoms of their mental disorders with nicotine. For some, nicotine abstinence may actually worsen symptoms of mental disorders.[10] Moreover, about 20 years ago, major tobacco US manufacturers recognized that a large proportion of their customer population was individuals with underlying psychiatric disorders. Knowing this, they began to craft advertisements and marketing of their nicotine products to target consumers with different psychological needs, such as using nicotine to manage mood, anxiety, stress, anger, social dependence, and insecurity.[11] 

Why is Quitting So Hard? 

Smoking cessation for individuals with psychiatric disorders is significantly more difficult than for healthy individuals for a variety of reasons. For one, smoking increases metabolism against antipsychotic medications. For example, smokers with schizophrenia would then have a lower ratio of serum concentration to dose of antipsychotics. Genetic differences influence which individuals will develop a nicotine addiction upon initial use of the drug. In particular, individuals with a fast metabolism may experience quicker nicotine withdrawal symptoms after being exposed to it, increasing the risk of nicotine dependency. The cessation process also involves addressing the fundamental deficit in cognitive processing that nicotine temporarily resolves. For example, in patients with schizophrenia, this deficit may be the psychotic symptoms.[12] 

Some individuals with a mental health illness may believe that the initial worsened feelings of anxiety and depression, withdrawal symptoms, upon cessation indicate that quitting nicotine will worsen their mental health. However, multiple researchers, such as Wu et. al (2023), have shown that long-term cessation of smoking among people with and without psychiatric disorders improved mental health outcomes. The incorrect psychological perception that smoking relieves stress prevents many people from trying to stop smoking. This distress is simply the cause of nicotine withdrawal, which would eventually end in long-term cessation.[13]

Smokers with a mental illness are also significantly more likely to develop nicotine withdrawal syndrome, where the symptoms of withdrawal are more severe and distressful. This heavy burden of withdrawal also makes it more difficult for a psychiatrically ill patient to quit. This makes nicotine withdrawal an important target for intervention for smokers with a mental illness.[14]

Starting the Journey to Stop Smoking 

Patients with a psychiatric illness and comorbid nicotine dependence are dying 25 years younger than the general population, from smoking-related illnesses such as heart and lung disease.[15] Understanding why these patients smoke, becoming dependent on nicotine, and what we can do to encourage smoking cessation would help prevent these premature mortalities.

Psychosocial support and medication are two types of treatment that have been published by the United States Public Health Service Guidelines in 2000 for general medical patients. However, these treatment types may not be completely suitable or applicable to psychiatric patients as well. Psychosocial support involves cognitive-behavior therapy (CBT) strategies to target identifying smoking cues, breaking the link between smoking and these cues, and learning alternative coping mechanisms. A formal program with other people trying to quit smoking may also contribute to the social aspect of support. Medications for nicotine replacement include bupropion, nortriptyline, clonidine, and varenicline. Identifying what a patient has already tried during their attempts to quit nicotine, as well as their mental and physical reactions to it, can help to determine what the next method of quitting can entail.[16]

If one is trying to quit, it is important to recognize that the cessation process will require constant effort. Overcoming withdrawal symptoms (e.g., feelings of irritability, anger, and depression) can be done by staying active, connected with people, and busy. Anxiety and depression levels are significantly reduced within the first few months of cessation, which means these withdrawal symptoms will decrease automatically, as well.[17] The Centers for Disease Control and Prevention (CDC) (2022) explains withdrawal symptoms that one may experience, and ways to manage them, including:[18] 

• Urges/Cravings

• Medications to quit 

• Avoiding triggers and cues to smoke (people one smokes with, places one smokes, activities one frequently does while smoking)

• Remind oneself why one is quitting

• Irritability/Anger

• Deep breaths

• Meditation

• Therapy

• Restlessness

• Physical activity

• Reducing caffeine intake

• Difficulty Concentrating

• Limiting activities with strong concentration for a short period of time

• Recognizing that this is an effect of nicotine withdrawal

• Trouble Sleeping

• Reducing caffeine, especially near bedtime

• Taking off nicotine patches at least an hour before sleeping

• Reducing electronic device usage

• Adding physical activity during the daytime

• Building a sleep schedule

• Excessive Hunger/Weight Gain

• Snacking smart

• Physical activity

• Mindfulness/focusing on eating while eating

• Anxiety or Depression Symptoms

• Physical activity

• Scheduling and organization

• Social interactions

• Rewarding yourself

• Speaking to a healthcare provider

If one is experiencing nicotine dependence and comorbid psychiatric illnesses, or having severe difficulty with quitting nicotine due to withdrawal symptoms, it is important to reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) or healthcare provider for guidance and support. 

Contributed by: Ananya Udyaver

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

References

1 U.S. Department of Health and Human Services. (2023, January 23). What is the scope of tobacco, nicotine, and e-cigarette use in the United States?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-scope-tobacco-use-its-cost-to-society  

2 U.S. Department of Health and Human Services. (2023b, February 24). Do people with mental illness and substance use disorders use tobacco more often?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-often 

3 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). Nicotine Addiction and Psychiatric Disorders. International review of neurobiology, 124, 171–208. https://doi.org/10.1016/bs.irn.2015.08.004 

4 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). Nicotine Dependence and Psychiatric Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(11):1107–1115. doi:10.1001/archpsyc.61.11.1107 

5 Ibid. 

6 Ibid. 

7 Ibid. 

8 Yuan, S., Yao, H. & Larsson, S.C. (2020). Associations of cigarette smoking with psychiatric disorders: evidence from a two-sample Mendelian randomization study. Sci Rep 10, 13807 https://doi.org/10.1038/s41598-020-70458-4 

9 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). 

10 Ibid. 

11 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). 

12 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). Smoking cessation in patients with psychiatric disorders. Primary care companion to the Journal of clinical psychiatry, 10(1), 52–58. https://doi.org/10.4088/pcc.v10n0109 

13 Wu A.D., Gao M., Aveyard P., Taylor G. (2023). Smoking Cessation and Changes in Anxiety and Depression in Adults With and Without Psychiatric Disorders. JAMA Network Open. 6(5):e2316111. doi:10.1001/jamanetworkopen.2023.16111

14 Smith, P. H., Homish, G. G., Giovino, G. A., & Kozlowski, L. T. (2014). Cigarette smoking and mental illness: a study of nicotine withdrawal. American journal of public health, 104(2), e127–e133. https://doi.org/10.2105/AJPH.2013.301502 

15 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). 

16 Centers for Disease Control and Prevention. (2023, February 10). People with mental health conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/groups/people-with-mental-health-conditions.html   

17 Ibid.

18 Centers for Disease Control and Prevention. (2022, December 12). 7 common withdrawal symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/7-common-withdrawal-symptoms/index.html 

The Impact of Unfulfilled Dreams

The Unrecognized Grief

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

Assumptive World

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

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

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

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

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

Recognizing the Grief

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

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

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

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

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

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

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

Finding new meaning to life

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

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

1. Understanding and accepting grief

2. Managing painful emotions

3. Planning for a meaningful future

4. Strengthening ongoing relationships

5. Telling the story of the loss

6. Learning to live with reminders

7. Establishing an enduring connection with memories of the loss

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

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

1. Acceptance or willing to experience negative emotions or thoughts

2. Cognitive defusion

3. Contact with the present moment 

4. Self as context

5. Values

6. Committed Action
   

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

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

Contributed by: Kelly Valentin

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

REFERENCES

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

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

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

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

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

6 Ibid.

7 Ibid.

8 Harris (2011)

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

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

11 Harris (2011)

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

13 Ibid.

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

15 Ibid.

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

17 Ibid.

18 Ibid.

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

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

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

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

23 Ibid.

24 Ibid. 

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 

How Birth Order and Sibling Relationships Shape Our Personality

Typical Traits Related to Birth Order

Approximately 80% of children in the United States grow up with at least one sibling[1], which makes us consider: how does having a sibling affect a child’s social development and personality? 

Comprehensive MedPsych Systems (2023) built a very thorough description and explanation for the traits that are often associated with each birth order. While these will not be applicable to everyone and all families, they are commonalities found among a family’s oldest child, middle children, youngest child and children without siblings based on parenting style and familial structure.

For example, a family’s oldest child (i.e., firstborns) are often responsible, independent, perfectionistic, rule-followers, role models, and hard workers. These traits are often developed from the attention that firstborns receive due to being the only child, as well as the care that first-time parents generally have with their oldest children. Parenting can be extremely scary and difficult; therefore, first-time parents are typically stricter.  Further, because this is their only child, they are able to devote all of their attention to this child. As siblings are introduced into the family, older children tend to develop leadership skills and responsibility as they are deemed as role models, often helping with household tasks (e.g., babysitting, chores).[2]

Middle children are often diplomatic, adaptable, funny, creative, sociable, rebellious, and competitive. These children are often trying to compete for attention with their other siblings and tend to be typically very flexible and more comfortable “going with the flow”. Middle children also have the unique experience of being the youngest child for some time before another sibling is born, but then can experience a shift toward the character of an older sibling, especially if there is a large age gap between them and the first-born.[3,4]

Youngest children are often outgoing, dependent, easy-going, mischievous, and free-spirited. They are typically deemed “the baby of the family” because they are not only the youngest, but also receive more attention from their parents as their siblings get older. Additionally, they tend to receive a more lenient and laid-back parenting style as third-time parents become more comfortable parenting. Dr. Catherine Salmon, a professor of psychology at the University of Redlands and co-author of The Secret Power of Middle Children, explains that “In general, high agreeableness, extraversion (the social dimension) and openness are associated with youngest children, and sometimes low conscientiousness due to lack of responsibilities and parental indulgence over expectations.”[5]

An only child shares many traits with first borns such as independence and leadership, but they are also known to be mature, loyal, sensitive, and confident. They are typically raised with their parent’s full attention, and as an only child, may be raised with higher expectations and pressure.[6] Krynen (2011) notes that the intelligence and motivation achievement scores are significantly higher, and they typically complete more years of education as well as obtain more prestige than those with siblings. Only children are also known to be very creative and imaginative, as they often spend more time alone and therefore, are more likely to invent imaginary friends or scenarios.[7] 

The Effect of Siblings on a Child’s Social Development

Sibling relationships are often vastly underestimated in their importance. While research often evaluates the effects of parental behavior on children’s development, their sibling relationships are often overlooked. However, Dr. Shawn Sidhu from the University of New Mexico, explains that siblings are often consistent sources for support and aid in the development of positive emotional competence because we share more information and confide in our siblings more often than we do our parents, specifically regarding topics such as friendships, relationships, and school.[8] 

Siblings also appear to one another as consistent sources for support and help children learn how to manage conflict and various socio-emotional skills at a young age, while many children without siblings don’t learn these behaviors until preschool or kindergarten. McHale et al. (2012) explains, “Through their conflicts, for example, siblings can develop skills in perspective taking, emotion understanding, negotiation, persuasion, and problem solving. Notably, these competencies extend beyond the sibling relationship and are linked to later social competence, emotion understanding, and peer relationships. In adolescence, siblings also contribute to positive developmental outcomes, including prosocial behavior, empathy, and academic engagement.”[9] McHale also confirms that those with close sibling relationships often have better mental health, better psychological health, and better social relationships.[10] Furthermore, even if siblings struggle to get along as kids, psychologist Jill Suttie (2022) explains that sibling relationships do change throughout their lifetime and often siblings become closer as they reach and extend into adulthood.[11]

While there are many positive effects that siblings can have on a child’s development, there are also some negative effects that can occur depending on the circumstances. Because a child is often surrounded by their siblings more than almost anyone else, an unhealthy or toxic sibling relationship can have detrimental effects on a child’s social development. Since siblings are often seen as support systems and are consistent in a child’s life, bullying from a sibling can be more devastating than peer bullying, as their home is no longer an escape.[12] 

Furthermore, psychiatrist Shawn Sidhu explains that children are often compared to their siblings in academic or athletic settings by coaches, teachers, and peers, which can lead to children internalizing their incompetence in comparison. This causes lower self-esteem, and can drive a wedge in their sibling relationship.[13]

Lastly, since older siblings are often role models for their younger siblings, negative or unhealthy behavior by the older siblings can introduce and encourage bad behavior for younger siblings.[14] Suttie (2022) explains, “Research confirms that if siblings have hostile or conflicted relationships when young, it can increase their risks of suffering anxiety, depressive symptoms, and even risky or antisocial behavior later in adolescence.”[15]

While several debates remain regarding which situation is better for a child’s development, having siblings or being an only child both have their unique sets of pros and cons. Additionally, while research has found that a person’s birth order tends to predict specific traits in each child due to both different parenting techniques and sibling competition, these traits are also affected by a slew of environmental factors such as the child’s age, sibling age gap, and family income.[16]

If you or someone you know would like to learn more about or are struggling with their family dynamic, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Kendall Hewitt

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

References

1 Weir, K. (2022). Improving Sibling Relationships. American Psychological Association, 53(2). 

https://www.apa.org/monitor/2022/03/feature-sibling-relationships#:~:text=Sibling%20warmth%20and%20support%20in,review%20of%20sibling%20dynamics%20in

2 What Your Sibling Birth Order Reveals About Your Personality Traits (Even If You’re an Only Child). (2023). Comprehensive MedPsych Systems. https://www.medpsych.net/2021/08/19/what-your-sibling-birth-order-reveals-about-your-personality-traits-even-if-youre-an-only-child/

3 Ibid.

4 Shanley, S. (2015). What Happens When The Youngest Child Becomes the Middle Child. The Washington Post. https://www.washingtonpost.com/news/parenting/wp/2015/03/23/what-happens-when-the-youngest-child-becomes-the-middle-child/ 

5 Comprehensive MedPsych Systems (2023)

6 Ibid.

7 Krynen, C. (2011). The Rise of Single-Child Families: Psychologically Harming the Child?  Intuition: The BYU Undergraduate Journal of Psychology, 7(1)(3). https://scholarsarchive.byu.edu/cgi/viewcontent.cgi?article=1191&context=intuition

8 Sidhu, S. (2019). The Importance of Siblings. The University of New Mexico Health Sciences Newsroom. https://hsc.unm.edu/news/news/the-importance-of-siblings.html

9 McHale, SM., Updegraff, KA., & Whiteman, SD. (2012). Sibling Relationships and Influences in Childhood and Adolescence. J Marriage Fam, 74(5), 913-930. doi:10.1111/j.1741-3737.2012.01011.x

10 Suttie, J. (2022). How Your Siblings Can Make You Happier. The Greater Good Science Center at the University of California, Berkeley. https://greatergood.berkeley.edu/article/item/how_your_siblings_can_make_you_happier 

11 Ibid.

12 Sidhu (2019)

13 Ibid.

14 Ibid. 

15 Suttie (2022)

16 Comprehensive MedPsych Systems (2023)

Exploring the Psychological Impacts of Participating in Sports

Tackling Mental Health 

Participating in competitive and high-performance sports is a multifaceted experience that can influence mental health in positive and negative ways. While sports offer numerous psychological benefits, they can also expose individuals to unique challenges that affect their well-being. 

The mental health impacts of participating in sports are extensive. From bolstering self-esteem and regulating emotions to fostering social connections and building resilience, the benefits of sports on mental well-being are undeniable. Individuals’ participation in sports not only strengthens their bodies but also nurtures their minds. 

While sports offers these many benefits, it's crucial to recognize that they can also have negative consequences for mental health. The pressures, injuries, social expectations, burnout and body image issues can all contribute to adverse psychological outcomes among athletes.

POSITIVE MENTAL HEALTH IMPACTS OF SPORTS

Participation in sports extends beyond physical fitness and competition. Engaging in sports has a profound impact on mental health, offering a range of psychological benefits that contribute to overall well-being. From boosting self-esteem to reducing stress, the effects of sports on mental health are becoming increasingly evident in research and everyday life. 

Enhanced Self-Esteem & Confidence

One of the most notable psychological benefits of engaging in sports is the significant boost in self-esteem and self-confidence, since participating in sports allows individuals to set and achieve personal goals, fostering a profound sense of accomplishment. Notably, Smith et al. (2019) found that athletes often exhibit higher self-esteem and a more positive self-image compared to non-athletes, and that consistent success in sports can translate into greater self-assurance in other areas of life, as well.[1] Additionally, Warburton et al. (2006) found that feeling physically fit and healthy can significantly boost an individual's self-esteem and self-confidence.[2]

Stress Reduction & Emotional Regulation

The Cleveland Clinic (2022) notes that regular physical activity releases endorphins which help relieve pain, reduce stress and improve mood.[3] Notably, Craft & Perna (2004) found that exercise through sports can lead to reduced stress, alleviation of symptoms related to anxiety and depression and improved emotional well-being.[4]

Social Interaction & Connection

Team sports, in particular, offer a unique opportunity for social interaction and the establishment of strong connections. The social connection formed through shared victories and defeats can lead to strong and lasting relationships. Jones et al. (2018) found that these social bonds among teammates can serve as a protective factor against mental health issues such as loneliness and depression.[5] Especially for individuals susceptible to feelings of isolation or loneliness, the sports environment can offer a supportive network that positively contributes to mental health.[6]

Lauren Becker Rubin, a former collegiate athlete at Brown University and current advisor to Haverford College’s varsity teams, spoke in depth about this topic in The Seattle Psychiatrist Interview Series. She explains that social connection is one of the biggest benefits of sports participation.[7] Particularly in being part of a team, individuals can find meaning in a sense of purpose while working together towards a common goal. She notes that there is a shared humanity in the wins, but more importantly also in the losses, as team members act as a support system for one another. Within the sports and team community there is group connection, fun, shared experience and striving for something bigger than oneself.[8]  

Improved Body Image & Self-Perception

Sports promote physical activity and fitness, which can contribute to improvements in physique and overall health. Thus, engaging in regular exercise can lead to a more positive body image and self-perception. Adams et al. (2020) note that as individuals see the positive changes in their bodies through training and participation, they often develop a greater appreciation for their physical selves, leading to increased self-acceptance and reduced body dissatisfaction.[9]

Goal-Setting Motivation

Goal setting is a common aspect of sports participation, whether it's achieving a personal best, improving a skill or winning a championship. The process of establishing, working towards and attaining these goals can significantly boost motivation, resilience and provide individuals with a sense of purpose. Emmons & McCullough (2003) highlighted the positive correlation between goal achievement and psychological well-being and found that engaging in goal-setting activates the brain's reward systems, releasing dopamine and reinforcing feelings of accomplishment.[10] 

Strengthened Mental Resilience

Participating in sports often involves facing challenges, setbacks, and even failures. These experiences help build mental resilience by teaching individuals how to adapt, learn from mistakes and persist. The skills learned in sports participation are transferable to other aspects of life, helping individuals manage stressors and overcome hardship with greater ease. Notably, Johnson et al. (2021) found sports participation enhances mental toughness and the ability to bounce back from life’s adversities.[11] 

Lauren Becker Rubin also discussed resilience in her interview, explaining that athletics builds resilience simply through the unpredictable nature of sports.[12] Never knowing if you’re going to win or lose makes us more adaptable and encourages us to learn how to manage emotions around unpredictable outcomes. Rubin notes that the resilience in sports is correlated to life: “There's ups and downs, there's good things, there's bad things. You have to learn to be able to manage your emotions around that and athletics really helps you do that.”[13] 

NEGATIVE MENTAL HEALTH IMPACTS OF SPORTS

While sports are celebrated for their many physical and psychological benefits, it's also important to acknowledge that sports participation isn't always a source of positive mental health. For some individuals, the pressures, expectations and experiences associated with sports can lead to negative psychological outcomes. 

Performance Anxiety & Stress

The competitive nature of sports can lead to high levels of performance anxiety and stress. In the Journal of Sport & Exercise Psychology, Stress et al. (2018) note that athletes are susceptible to performance-related anxiety, which can have adverse effects on mental health.[14] Athletes may experience overwhelming pressure to perform consistently at their best, which can result in debilitating stress and anxiety. 

Rubin speaks to performance anxiety in her interview and explains how the public stage athletes are on opens the door to stress, anxiety, pressure, worry and fear. Athletes’ fear is multifaceted, as she describes there is “fear of losing, fear of winning, fear of embarrassment, fear of getting injured, fear of losing social status, fear of losing your position - so there's a lot of fear, worry, stress and anxiety about performing.”[15] These stressors affect athletes both on and off the field as these fears do not always subside once someone is away from the competition.

Injury-Related Mental Health Issues & Identity Crisis

Injuries are a common part of sports, and they can have serious impacts on an athlete's mental health. Whether an athlete suffers a season-ending injury, one that sidelines them for a handful of games or one that only limits their performance, Timpka et al. (2017) explain how the physical pain and the fear of lost opportunities can lead to symptoms of depression, anxiety and even post-traumatic stress disorder (PTSD).[16]

In her interview, Rubin acknowledges injury-related mental health issues, particularly concerning a loss of identity. When an athlete or individual suffers an injury it can affect their sense of self, especially if participation in sports is a part of one's daily life.[17] Often, athletes have been athletes for much of their lives, so when a time comes where they cannot play or their role has changed, an identity issue can arise. Even retirement from a sports career can be mentally and emotionally challenging, as athletes often face an identity crisis when their sporting journey ends. In particular, Lavallee et al. (2012) note that the transition to a life outside of sports can lead to feelings of loss, depression, and anxiety.[18] 

Social Pressure & Isolation

Despite the comradery, sports can be isolating for some individuals, particularly those who struggle to meet the expectations of their peers, coaches or parents. Smith et al. (2020) notes athletes’ fear of judgment or rejection can lead to social anxiety and feelings of isolation.[19] Failing to meet the expectations of others, self-shame and the pressure to succeed can have adverse effects on one’s mental health.

Rubin speaks to the pressure all athletes face while performing on a public stage, but notes that it is increasingly challenging the more competitive the participation becomes. She describes how social media, fans, money, and contracts are just a few aspects of the pressure elite athletes face on a daily basis. While recreational sports have their own unique set of stressors as well, Rubin describes that the “pressure, stress, anxiety, worry, isolation, just really ramps up the higher you get” in competition.[20] 

Burnout & Overtraining

Raedeke et al. (2002) stress the links between burnout and negative mental health outcomes in athletes.[21] The drive for success in sports can often lead to overtraining and burnout, which can result in physical and mental exhaustion. Additionally, athletes may lose their passion for the sport, experience symptoms of depression and face difficulties in other aspects of life (e.g., relationships, school or work). Overtraining and burnout are especially problematic among competitive athletes, who often spend most of their free time training, with few days off from training per year,

Eating Disorders & Body Image Issues

Sports that emphasize weight and appearance (e.g., gymnastics, wrestling) can contribute to the rise of eating disorders and body image issues. Joy et al. (2016) found there is a high prevalence of eating disorders among athletes due to the physical demands of sports as well as unhealthy expectations of physique, diet and exercise.[22] Athletes may develop unhealthy relationships with food and their bodies, which can have lasting psychological effects. 

It's essential to provide support and resources for athletes throughout their careers to address these mental health challenges and create a more balanced, nurturing sports environment. Regardless of age and level, this support includes promoting mental health awareness, reducing stigma for those who are suffering, providing access to mental health professionals and fostering a culture that values athletes' well-being over their performance or success.

If someone or someone you know is struggling with the stressors of competing in sports, reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. 

Contributed by: Jordan Denaver

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

REFERENCES

1 Smith, J., et al. (2019). Psychological correlates of university athletes and nonathletes: An exploration of the mental health hypothesis. Journal of Sport and Exercise Psychology, 41(2), 97-103.

2 Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health benefits of physical activity: The evidence. CMAJ: Canadian Medical Association Journal, 174(6), 801-809.

3 Cleveland Clinic. (2022, May 19). Endorphins: What they are and how to boost them. https://my.clevelandclinic.org/health/body/23040-endorphins

4 Craft, L. L., & Perna, F. M. (2004). The Benefits of Exercise for the Clinically Depressed. Primary Care Companion to the Journal of Clinical Psychiatry, 6(3), 104-111.

5 Jones, A., et al. (2018). The Impact of Team Sports on Mental Health in Adolescents: A Systematic Review. Journal of Sport and Social Issues, 42(1), 3-22.

6 Ibid.

7 Denaver, J. E., & Rubin, L. B. (2023). Certified Mental Performance Coach Lauren Becker Rubin on the Mental Health of Athletes. Seattle Anxiety Specialists, PLLC. https://seattleanxiety.com/psychology-psychiatry-interview-series/2023/7/14/certified-mental-performance-coach-lauren-becker-rubin-on-the-mental-health-of-athletes

8 Ibid.

9 Adams, K., et al. (2020). Sports involvement and body image: The mediating role of physical activity and body composition. Journal of Eating Disorders, 8(1), 1-12.

10 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.

11 Johnson, R., et al. (2021). The relationship between sports participation, resilience, and mental health in college athletes. Journal of Sport and Exercise Psychology, 43(3), 195-203.

12 Denaver & Rubin (2023)

13 Ibid.

14 Stress, A. B., et al. (2018). Performance Anxiety and Coping in Athletes. Journal of Sport & Exercise Psychology, 40(6), 292-301.

15 Denaver & Rubin (2023)

16 Timpka, T., et al. (2017). The Psychological Health of Injured Athletes. Journal of Athletic Training, 52(3), 231-238.

17 Denaver & Rubin (2023)

18 Lavallee, D., et al. (2012). Retirement from Sport and the Loss of Athletic Identity. Journal of Applied Sport Psychology, 24(4), 362-379.

19 Smith, R. E., et al. (2020). Interpersonal Stressors and Resources as Predictors of Athlete Burnout. Journal of Sport & Exercise Psychology, 42(1), 65-75.

20 Denaver & Rubin (2023)

21 Raedeke, T. D., Lunney, K., & Venables, K. (2002). Understanding athletes burnout: Coach perspectives. Journal of Sport Behavior, 25(2), 181.

22 Joy, E., et al. (2016). Prevalence of Eating Disorders and Pathogenic Weight Control Behaviors Among NCAA Division I Female Collegiate Gymnasts and Swimmers. Journal of Eating Disorders, 4(1), 19.

Developments in Art Therapy for Mental Health

What Words Can’t Express 

The process of making art, like literature, has long been shown to have mental and emotional health benefits. The APA describes art therapy as a type of psychotherapy that helps provide a way to express emotions and experiences not easily expressed in words.[1] The artist Georgia O’Keeffe said, “I found I could say things with color and shapes that I couldn’t say any other way – things I had no words for.” 

The American Art Therapy Association explains that art therapy includes active art-making, the creative process, and applied psychological theory - within a psychotherapeutic relationship - to enrich the lives of individuals, families, and communities.[2] Furthermore, art therapy is used to foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills and reduce conflicts and distress. Although art therapy has been used to treat a range of mental health disorders including anxiety and depression, this type of therapy is particularly applicable to survivors of trauma because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often “wordless and visual nature of traumatic memories.”[3]

MechanismS of Art Therapy  

Art therapy engages the mind, body, and spirit in ways that are distinct from verbal communication. In an article published in the Journal of the American Art Therapy Association, Lusebrink 2010 differentiates art therapy from verbal therapies by the use of art media as a means of expression and communication, the multileveled meaning present in visual expressions, and the therapeutic effects of the creative process.[4] In a schematic framework known as the Expressive Therapies Continuum (ETC), three distinct levels (kinesthetic/sensory, perceptual/affective, and cognitive/symbolic) reflect different functions and structures in the brain that process visual and affective information.[5]  

This is particularly useful because the art therapist can first assess the client’s cognitive and emotional functioning through these different ETC levels in order to better address their strengths, challenges, and progress in art therapy. For example, Hendler et al. (2001) found that in individuals with post-traumatic stress disorder (PTSD), affectively-charged visual stimuli activate limbic regions and sensory areas of the cerebral cortex but not the prefrontal area. This is significant, as visual processing within non-PTSD individuals does include the prefrontal cortex which is critically involved in the emergence of conscious visual perception. On the other hand, client areas of strength would constitute a lack of difficulty in processing visual information on particular levels of the ETC. This framework is useful for helping art therapists determine where the “missing links'' are in terms of the sequence of visual information processing. 

These assessments can act as guidelines for starting points, pathways, and goals in art therapy.[6] The range of kinesthetic, sensory, perceptual, and symbolic opportunities also allow clients to practice and create alternative modes of expressive communication, which can help circumvent the limitations of language.[7] 

Art Therapy Sessions 

Though one can always choose to pursue the arts on their own time to calm and relax the mind, formal art therapy sessions are typically carried out by licensed clinicians, master's-level or higher degree holders trained in art and therapy work. Art therapists work with diverse populations in a variety of settings including hospitals, schools, veterans’ clinics, private practice and psychiatric and rehabilitation facilities.[8] One may choose to engage in a private art therapy session or a group setting with other individuals. 

Before beginning, it is important for the therapist to emphasize that the client does not need to be artistically or creatively inclined to benefit from this process. During a typical session, clients will engage in both art-making and meaningful conversation with the therapist.[9] The therapist's main goal is to describe the goal of art therapy, help the client choose an appropriate medium for expression (e.g., collage, painting, sculpture, drawing), and prompt the client with questions which will shape and guide the art making session. At the conclusion of the session, the therapist and client will debrief. To make sense of the process, they may collaboratively discuss any emotions and feelings that arose during the art making process, the work of art itself and its potential meanings, as well as plans for future sessions.[10] 

Applications for Addressing Trauma 

Art therapy has historically been used to address and treat trauma for a variety of reasons. Art is an effective means of expressing past trauma from a safe environment; it provides emotional distance from the actual event and provides an alternative outlet to confront unresolved trauma memories through the use of symbols and visual media. Additionally, PTSD UK notes how new research has found that art therapy fosters a mind-body connectedness and allows the brain to use mental and visual imagery.[11]

In 2016, Campbell et al. (2016) conducted research to examine the impact of art therapy on those with combat-related PTSD. They administered a series of art therapy sessions in which participants engaged in creating a visual trauma narrative, mapping representations of their emotions, making images of the self before and after the trauma and creating final reflective art pieces. Results from a depression scale score showed that although not statistically significantly different, a trend toward greater reduction in depression symptoms for the test group compared to the control was noted.[12] Although these quantitative measures did not show statistical significance, a more recent study by Berberian et al. (2019) examined the qualitative outcomes of art therapy, or more specifically, montage painting, for active-duty military service members with traumatic brain injuries or PTSD. They found that group art therapy elicited improvement in interpersonal relatedness, as well as the expression of hopefulness and gratification. Art therapy allowed the individuals to work toward creating an individual trauma narrative which is a key component for recovery and healing.[13]

Aside from veterans and active-duty military service members, PTSD within children and early relational trauma has also been addressed through art therapy. Individuals who have experienced trauma at a young age show increased levels of suicide, alcohol addiction, and/or drug addiction later in life, thus art therapy is especially valuable as an early intervention for children who have been exposed to trauma in a variety of contexts and in different forms (e.g., witnessed or experienced gang violence, bullying, loss and grief, domestic abuse, suicide, homelessness, and drug abuse).[14] A study conducted by Woollett et al. (2020) invited school-aged children and their mothers in domestic violence shelters to participate in a pilot study aiming to integrate trauma-informed art and play therapy with traditional cognitive behavioral therapy (CBT). From baseline levels, children's depressive symptoms showed significant reduction and improvement in PTSD symptoms.[15] 

Another specific context which art therapy has been applied to is early relational trauma. This type of trauma is distinct from post-traumatic stress disorder in its emphasis on childhood abuse, various forms of neglect, and other neurological effects that occur during a specific time period when the developing brain was exposed to prolonged trauma.[16] Art therapy can be particularly helpful for early relational trauma clients who exhibit anger and frustration as they struggle to confront and articulate their emotions. The art they make is a non-verbal activity that reflects, mirrors and amplifies expression of the client's internal state of affects. A study by Chong (2015) presented a collection of clinical vignettes in which she notes that school-aged children with early relational trauma showed improvement in dimensions such as confidence, attention span, and the formation of positive relationships in school settings.[17]

Within communities of all ages and backgrounds, art therapy is a flexible, effective and low-intensity intervention for individuals dealing with trauma which can cultivate a greater sense of creativity, empowerment, and independence while fostering a healthy psychosocial relationship with themselves and others.[18] 

If you or someone you know would like to learn more about art therapy and how to incorporate it into your own life, 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 (2020, January 30). Healing Through Art - APA Blogs - Patients and Families. American Psychiatric Association. https://www.psychiatry.org/news-room/apa-blogs/healing-through-art#:~:text=Art%20therapy%2C%20a%20type%20of,the%20process%20of%20making%20art 

2 American Art Therapy Association. (2014). American Art Therapy Association. https://arttherapy.org/ 

3 Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2018). Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study. Journal of Trauma & Dissociation, 20(1), 114–130. https://doi.org/10.1080/15299732.2018.1502712 

4 Lusebrink, V. B. (2010). Assessment and Therapeutic Application of the Expressive Therapies Continuum: Implications for Brain Structures and Functions. Art Therapy, 27(4), 168–177. https://doi.org/10.1080/07421656.2010.10129380

5 Expressive Therapies Continuum: Three-Part Healing Harmony | Psychology Today. (December 30, 2018). Www.psychologytoday.com. https://www.psychologytoday.com/us/blog/arts-and-health/201812/expressive-therapies-continuum-three-part-healing-harmony 

6 Lusebrink (2010) 

7 American Art Therapy Association 

8 Ibid. 

9 Homepage - The British Association Of Art Therapists. (2022, September 26). The British Association of Art Therapists; BAAT. https://baat.org/ 

10 What Is Art Therapy? | Psychology.org. (2022, February 15). Www.psychology.org. https://www.psychology.org/resources/what-is-art-therapy/#:~:text=During%20a%20session%2C%20an%20art 

11 How art therapy has helped those with PTSD – PTSD UK. (n.d.). https://www.ptsduk.org/how-art-therapy-has-helped-those-with-ptsd/ 

12 Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art Therapy and Cognitive Processing Therapy for Combat-Related PTSD: A Randomized Controlled Trial. Art Therapy, 33(4), 169–177. https://doi.org/10.1080/07421656.2016.1226643 

13 Berberian, M., Walker, M. S., & Kaimal, G. (2018). “Master My Demons”: art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Medical Humanities, 45(4), 353–360. https://doi.org/10.1136/medhum-2018-011493 

14 Helping Kids Cope with Trauma. (October 20, 2017). Cedars-Sinai. https://www.cedars-sinai.org/blog/art-therapy-helps-children-cope-with-trauma.html#:~:text=Art%20therapy%20teaches%20kids%20how 

15 Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107(1), 104564. https://doi.org/10.1016/j.chiabu.2020.104564 

16 Terradas, M. M., Poulin-Latulippe, D., Paradis, D., & Didier, O. (2020). Impact of early relational trauma on children’s mentalizing capacity and play: A clinical illustration. European Journal of Trauma & Dissociation, 100160. https://doi.org/10.1016/j.ejtd.2020.100160 

17 Chong, C. Y. J. (2015). Why art psychotherapy? Through the lens of interpersonal neurobiology: The distinctive role of art psychotherapy intervention for clients with early relational trauma. International Journal of Art Therapy, 20(3), 118–126. https://doi.org/10.1080/17454832.2015.1079727 

18 Boyadjis, A. (2019). Healing the Child Through Expressive Arts Therapy. https://minds.wisconsin.edu/bitstream/handle/1793/79197/Boyadjis%2C%20Andrea%20Thesis%202019%20compiled.pdf?sequence=1&isAllowed=y