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)

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 

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 

From Late Detection to Self-Discovery: Diagnosing Autism in Adulthood

Navigating New Horizons

Adulthood is often celebrated as a time of personal growth, independence, and achieving milestones (e.g., buying a home and career advancement). Each life experience involves responsibilities, unexpected life circumstances, and challenges that mold an individual. Amidst the whirlwind of adult life, how does one navigate an adulthood diagnosis of autism spectrum disorder (ASD)? Typically, ASD is diagnosed during childhood, where an individualized plan and support may more readily exist. While adults can achieve numerous feats, receiving an autism diagnosis in adulthood can be a validating and liberating experience.

Adulthood Autism Diagnosis Journey 

Autism is a neurodevelopmental condition categorized by challenges in two main areas: communication and interaction with others, and repeated certain behaviors or focus on particular interests.[1] Common indicators of autism include interpreting statements literally, struggling to grasp others' thoughts or words, experiencing heightened anxiety in social situations, and maintaining a strict daily routine - with anxiety arising from any alterations to it.[2] The most effective way to diagnose autism involves working with a team of licensed mental health and healthcare professionals (e.g., primary care doctor, neurologist, psychiatrist) with experience in autism. These trained professionals observe an individual's behavior and review their medical and developmental history.[3]

Behaviors consistent with autism must have manifested during childhood, making it crucial to recollect those exhibited during that period in an interview or questionnaire. The assessment can still be completed if an individual cannot recall developmental histories. Furthermore, an individual's family members can participate in the evaluation and provide developmental histories.[4] Throughout the assessment process, individuals should anticipate questions that pertain to difficulties in navigating social communication and interaction, sensory sensitivities, repetitive behaviors, and highly specific interests.[5] Following the assessment, an individual may receive a diagnosis of autism or not. If an autism diagnosis is confirmed, it is recommended to actively seek support and ongoing services, and access available resources to address any questions or concerns.

Self-Perception Before and After Diagnosis

The stigma that may accompany an autism diagnosis is often shaped by how the public interprets the observable traits of Autistic individuals. Turnock et al. (2022) notes that various factors can moderate or influence this stigma, including the extent and quality of interactions with autistic individuals, cultural influences, gender differences, personal variations, and how a diagnosis is revealed or disclosed.[6] Addressing and diminishing this stigma promotes greater awareness, simplifies the diagnosis process, and provides a more supportive environment for those with autism.[7]

A study by Leedham et al. (2019) examines the experience of 11 adult participants who received an autism diagnosis aged at, or over, 40 years.[8] The nine-question interview resulted in answers that can be categorized into themes, including: 

• a hidden condition

• the process of acceptance

• the impact of others post-diagnosis

• a new identity on the autism spectrum 

The 11 participants expressed their life experiences and self-perception before their diagnosis. Some participants stated that they internalized beliefs of being "wrong," "flawed," or "bad" because of connections that felt "failed".[9] Participants shared that they mimicked "normal" behaviors as a survival function, but that these behaviors resulted in feelings of exhaustion and unhappiness.[10]

A study by Stagg & Belcher (2019) examined 9 participants between the ages of 52 and 54 who received their autism diagnosis later in life.[11] This cohort shared similar life experiences to the Leedham et al. study, with some participants indicating they “never made friends”, social events were difficult, and they felt utterly isolated.[12] Additionally, two studies by Atherton et al. (2021) examined a total of 428 participant's life experiences to measure their quality of life relative to their diagnostic age. The correlation found that the diagnostic age later in life was associated with poorer quality of life. The participants stated painful experiences that affected their self-perception amidst sensory discomforts and recalling social miscommunications.[13]

Conversely, Leedham et al. note that after diagnosis, participants expressed feeling more free, better about themselves, less anxiety, and better self-awareness.[14] Participants indicated they had devised positive coping strategies to address anxiety and being overwhelmed. Lastly, there was a significant shift from self-judgment to self-empathy once they were aware of their diagnosis. Stagg & Belcher note that participants indicated post-diagnosis: feeling like it was a eureka moment, a complete relief, being stunned because it was not obvious to them before, and identifying that now they are viewing themselves in a different light.[15] Likewise, Atherton et al. (2021) found that their participants expressed that the diagnosis brought a sense of clarity.[16]

Value of Adulthood Autism Diagnosis

After interviewing participants diagnosed later in life, there were a few repeating challenges expressed throughout navigating the diagnostic process. These challenges included the obstacles of getting diagnosed, weighty emotional responses, and realizing the diagnosis explains the differences they recognized about themselves earlier in life.[17] The assessment's waitlist and wait times, lack of autism specialists, and the cost of care were specific obstacles highlighted in the studies. Throughout the interviews, participants noticed there was a lack of public awareness about autism, which contributed to their unmet needs. However, they could see that their autistic traits matched others with autism or the diagnosis criteria.[18] 

Participants explained that their late diagnosis was due to the lack of awareness about autism during their childhoods. Although family members had suspicions, they were unable to find explanations why their child did not appear neurotypical. Later in life, when participants received their diagnosis, they experienced relief and emotional validation. Additionally, the new diagnosis assisted participants in understanding their identity and challenges in a new light. One participant expressed that being able to articulate themselves and their diagnosis better was amazing and validating. Ghanouni & Seaker (2023) noted that although participants knew they were different from a young age, the new understanding allowed them to re-examine their previous life experiences.[19] The diagnosis allowed participants to explain their understanding of their needs and their relationships. For example, Leedham et al. (2019) explains that a participant’s partner can now take the lead in situations where they know the participant is uncomfortable, whereas in the past they might have thought their partner was simply acting awkwardly.[20] 

Understanding Co-Occurring Conditions: Autism & Comorbidities

Navigating the path to an adult autism diagnosis is a multi-faceted journey that extends well beyond receiving a single diagnosis and is rarely homogenous. Autism frequently intersects with other conditions, collectively known as co-occurring conditions or comorbidities. A recent study by Jadav and Bal (2022) delved into the correlation between the age of diagnosis and the emergence of co-occurring psychiatric conditions among adults on the autism spectrum.[21] They found that adults who received their autism diagnosis at the age of 21 or older reported significantly higher rates of anxiety disorders, depression, and dysthymia than those diagnosed before the age of 21.

These findings underscore the importance of comprehending the impact of various psychiatric conditions on the lives of adults with autism. In particular, life experiences (e.g., enduring societal exclusion, grappling with a diminished self-image, and enduring bullying) can significantly contribute to the prevalence of depression and anxiety disorders among this population.[22] Furthermore, the study highlights that generational mental health stigmas and a lack of awareness can influence the timing and willingness of adults to seek a diagnosis. According to Barlattani (2023), ADHD has the highest prevalence among psychiatric comorbidities in autism, followed by anxiety disorders. 70% of people with autism experience one comorbid psychiatric disorder, increasing the need to adapt and implement diagnostic tools for adults with autism.[23] Thus, acquiring a proper and valid diagnosis proves invaluable by offering autistic individuals of all ages significant benefits, especially for those experiencing comorbid conditions.

If you or someone you know has or suspects that they have Autism Spectrum Disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. Note: the University of Washington’s UW Autism Center offers many resources and provider options.

Contributed by: Kelly Valentin

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

references

1 Ghanouni, P., & Seaker, L. (2023). What does receiving autism diagnosis in adulthood look like? Stakeholders’ experiences and inputs. International Journal of Mental Health Systems, 17(1). https://doi.org/10.1186/s13033-023-00587-6

2 Signs of autism in adults. (2023, March 8). nhs.uk. https://www.nhs.uk/conditions/autism/signs/adults/

3 Ghanouni & Seaker (2023)

4 Autism spectrum Disorder. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

5 Ibid.

6 Turnock, A., Langley, K., & Jones, C. R. G. (2022). Understanding Stigma in Autism: A Narrative review and Theoretical model. Autism in Adulthood, 4(1), 76–91. https://doi.org/10.1089/aut.2021.0005

7 Ibid.

8 Leedham, A., Thompson, A. R., Smith, R., & Freeth, M. (2019). ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood. Autism, 24(1), 135–146. https://doi.org/10.1177/1362361319853442

9 Ibid.

10 Ibid.

11 Stagg, S. D., & Belcher, H. (2019). Living with autism without knowing: receiving a diagnosis in later life. Health Psychology and Behavioral Medicine, 7(1), 348–361. https://doi.org/10.1080/21642850.2019.1684920

12 Leedham, A., Thompson, A. R., Smith, R., & Freeth, M. (2019). ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood. Autism, 24(1), 135–146. https://doi.org/10.1177/1362361319853442

13 Atherton, G., Edisbury, E., & Piovesan, A. (2021). Autism Through the Ages: A Mixed methods approach to understanding how age and age of diagnosis affect quality of life. Journal of Autism and Developmental Disorders, 52(8), 3639–3654. https://doi.org/10.1007/s10803-021-05235-x

14 Leedham et al., (2019)

15 Stagg & Belcher (2019)

16 Atherton et al., (2021)

17 Ghanouni & Seaker (2023)

18 Ibid.

19 Ibid.

20 Leedham et al., (2019)

21 Jadav, N., & Bal, V. H. (2022). Associations between co‐occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research. Autism Research, 15(11), 2112–2125. https://doi.org/10.1002/aur.2808

22 Ibid.

23 Barlattani, T. (2023). Autism spectrum disorders and psychiatric comorbidities: a narrative review. Journal of Psychopathology. https://doi.org/10.36148/2284-0249-N281

Protecting our Most Vulnerable: The Suicidality Crisis in Black Children

A Call to Action

In April 2019 the Congressional Black Caucus (CBC) gathered to confront the pressing concern over Black children who were dying by suicide at an unprecedented rate in America.[1] After its meeting, the caucus determined that it was their responsibility to identify this crisis as a Black health emergency, and subsequently built a coalition that has since spent the past four years working towards solutions. 

The suicidality issue amongst young Black Americans initially came as a surprise to the CBC and other researchers within the mental health sector. Historically, the suicide rate within the overall Black community has been lower than that of the national average, particularly in comparison to White Americans.[2] Even between 2021 and 2022 the Center for Disease Control (CDC) recorded 48,183 suicides within the United States, with only 7% of the group identifying as Black American.[3] However, a closer look at suicide trends began to indicate a growing rate in Black children. Price & Khubchandani (2020) analyzed data between 2001 and 2017, discovering that the rate of suicides in young Black men and women increased by 60% and 182%, respectively.[4] They also found that suicide was the second highest cause of death for Black adolescents.[5]

Research conducted by the CDC in 2021 also drew similar conclusions: Black male children aged five to 11 are at risk to the point where they are twice as likely to die by suicide over their White counterparts.[6] Similarly, the Journal of the American Academy of Child & Adolescent Psychiatry analyzed data between 2003 to 2017 and found Black girls between the ages of 15 to 17 had the largest percentage in suicides of all race and gender-based demographics.[7]

Understanding the “Why” behind Black Youth Suicidality

With Black children dying by suicide at such an unprecedented rate, the CBC began to focus on the causes, supposing that each cause would later have an accompanying solution it could implement in order to address this crisis. While all children are vulnerable to bullying, issues with self-identity, and hormonal changes that can cause depression and suicidal ideations, the CBC found that the compounding impacts of trauma, cultural stigmas, and socioeconomic barriers are uniquely faced by Black children. Mathew et al. (2020) found that of children who attempt suicide, having a hostile family environment and perceiving a lack of care from family members within a household have been discovered as contributing factors to suicidal behavior among adolescents and young adults.[8] Black children have the highest likelihood of witnessing home violence, experiencing communal stigmas in response to mental crisis, and enduring distressing racism and discrimination, all of which have the potential to exacerbate their likelihood of not wanting to live.[9,10] In the face of these compounding factors, young Black men often feel a sense of hopeless that is further aggravated by the racism and discrimination they face within society.[11] Black girls also combat the complex intersectionality of race and gender-based discrimination, encountering racism while also having a higher likelihood than their male counterparts of being sexually assaulted. With race and gender-based pressures mounting, young Black women have a singular struggle in overcoming sexual harassment, misogyny, and racism - all of which make them more vulnerable to depression and suicidal ideations.[12]

The Necessity of Support

For all children, familial and community support play pivotal roles in mental health outcomes. A strong support system can serve as a protective factor against suicide, especially for Black children where familial support and communalism are heavily integrated in Black culture.[13] In the absence of a strong support system, children often feel isolated and have a higher likelihood of experiencing depression and/or suicidal ideation.[14] In a 2020 report conducted by the U.S. Department of Health and Human Services, researchers concluded that Black children had a high likelihood of experiencing crisis in the two weeks prior to their death by suicide.[15] Further, nearly 40% of Black youth had a crisis or dispute with a family member, romantic partner, or friend before their death by suicide; 30% of this group had an argument within 24 hours of their death.[16] Within the Black community, providing accessible resources to navigate relationship issues and familial trauma can provide useful support to save a child’s life.

The Trouble in Exhibiting Mental Health Issues

For all children suffering from depression and mental health struggles, early detection and timely treatment are essential to mitigating their symptoms. However, Black children are the most likely to be suspended, expelled, or labeled with “behavioral issues” when they are actually displaying mental health issues. A 2015 study conducted by Okonofua & Eberhart concluded that educators often perceive black students’ behaviors as more problematic and more punishable than those of their White counterparts.[17] This study not only exhibits racial disparities in disciplinary action, but it also points to the isolation Black children face in the midst of a crisis. 

The Lack of Mental Health Intervention

While intervention is key to preventing a child from getting to the point where they attempt suicide, mental health issues remain underdiagnosed and stigmatized within the Black community. In its 2020 report to Congress, the U.S. Department of Health and Human Services identified this contradiction: despite dying by suicide at a faster rate than any other racial/ethnic group, Black youth had lower reported rates of known mental health problems and documented histories of suicidal thoughts or plans. However, the lack of reported rates of mental health issues is not equivalent to these problems being nonexistent for Black children. On the contrary, the low rates of recorded mental health disorders that stand in contrast to the high rates of past suicide attempts suggest that Black youth are still experiencing depression, but they have limited access to mental healthcare and proper treatments. Not only do Black children face barriers to attaining effective mental health resources because of the high cost of therapy, but the American Psychological Association (APA) note the United States has a shortage of culturally-competent therapists across the country.[18] With over 88% of mental health providers identifying as white, young Black children continue to have more difficulty finding therapists that look like them and with whom they can identify.[19]

Mental Health Stigma Within the Black Community

Within the Black community, mental health conditions are not only misunderstood, but many Black adults view mental health conditions as a weakness.[20] As a result, people within this community may face embarrassment about their mental health condition and worry that they may be ostracized if they share how they are struggling with friends or family.[21] This perspective is not only damaging to Black adults, who will often mask their mental health disorders, but also to Black children who are the most vulnerable and often also the most susceptible to being silenced in a time of distress.[22] 

Further, another obstacle for this cohort is that many Black Americans turn to spirituality and a faith-based community rather than seeking a medical diagnosis.[23] While spirituality is a proven source of resiliency for many ethnic minorities and can provide healthy outlets and reduce isolation, it is not always effective or effective enough in crisis.[24] In contrast, children should be encouraged to seek out multiple treatment avenues to ensure the highest chance of recovery from mental illness.

Solutions to the Suicide Crisis 

The CBC concluded that addressing the issue of youth suicide within the Black community demanded a comprehensive approach that continues to consider the complex intersection of mental health, cultural, and socioeconomic factors. They note the following factors are essential to halting the trend of Black children ending their lives:

1. Schools stand at the forefront of community-based care and they can close the gap in mental-health access by offering all students access to affirming environments and well-trained professionals. Unlike mental health care provided by hospitals, mental health professionals in schools have the ability to provide resources and assistance to students without the barriers of insurance and financial security. Schools within a child’s community also have the potential to help a child overcome their mental health challenges with culturally-relevant care.

2. Expanding access to underprivileged communities has the potential to give Black children access to treatment that would otherwise be unavailable. As the American Psychological Association (APA) asserts, telehealth with expanded coverage via the assistance of insurance companies is an equity-based solution that may allow Black children to get the treatment they are seeking.[25]

3. Black researchers must also be given adequate funding and support in order to narrow the knowledge gap that leaves Black-specific illnesses underreported. Research topics proposed by Black scientists are less likely to be funded, leaving profound gaps in the level of understanding that is required to protect Black youths from the unique challenges they face.

In 2019, Congresswomen Coleman and Napolitano led the CBC in proposing the “Pursuing Equity in Mental Health Act.” The act has successfully passed the House of Representatives, and once it is officially enacted it will provide $750 million annually between fiscal years 2024 to 2029 for the National Institute on Minority Health and Health Disparities.[26] The future act will also authorize $150 million dollars to the National Institutes of Health (NIH) to build mental health facilities within Black communities, support clinical research, and work to end racial/ethnic disparities in healthcare.[27]

Ensuring Children Have Hope in their Future

Ultimately, Black children face the unique challenge of navigating their lives at the intersection of race, gender, and sexual orientation all while carrying the basic challenge of simply “being kids”. With societal pressures and feelings of isolation becoming prevalent within the current generation, it is essential for the adults within their lives to make sure that they are protected and supported. Children are a vulnerable population who are not fully capable of self-advocacy, and for this reason the rising suicide rates among Black children necessitates collective action. By addressing the mental health stigma within the Black community, systemic inequalities and cultural factors, American society will build a mental healthcare system where, regardless of their background, all children feel supported and capable of overcoming trauma.

If you or someone you know is struggling with depression, hopelessness and/or suicidal thoughts, please call 911, 988, or go to the closest emergency room. Individuals seeking non-crisis support can also reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and additional resources. 

Contributed by: Kate Campbell

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

References

1 Coleman, B.W. (2023). Emergency Task Force on Black Youth Suicide and Mental Health.https://watsoncoleman.house.gov/suicidetaskforce/

2 Kung, K. C., Liu, X., & Juon, H. S. (1998). Risk factors for suicide in Caucasians and in African-Americans: a matched case-control study. Social psychiatry and psychiatric epidemiology, 33(4), 155–161. https://doi.org/10.1007/s001270050038

3 Langston, L. & Truman, J.L. (2014). Socio-Emotional Impact of Violence. Bureau of Justice Statistics. https://bjs.ojp.gov/library/publications/socio-emotional-impact-violent-crime

4 Price, J. H., & Khubchandani, J. (2019). The Changing Characteristics of African-American Adolescent Suicides, 2001-2017. Journal of community health, 44(4), 756–763. https://doi.org/10.1007/s10900-019-00678-x

5 Ibid

6 Meza, J.L., Patel, K., Bath, E. (2022). Black Youth Suicide Crisis: Prevalence Rates, Review of Risk and Protective Factors, and Current Evidence-Based Practices. Focus: The Journal of Lifelong Learning in Psychiatry, 20(2), 197-203. https://doi.org/10.1176/appi.focus.20210034

7 Sheftall, A. H., Vakil, F., Ruch, D. A., Boyd, R. C., Lindsey, M. A., & Bridge, J. A. (2022). Black Youth Suicide: Investigation of Current Trends and Precipitating Circumstances. Journal of the American Academy of Child and Adolescent Psychiatry, 61(5), 662–675. https://doi.org/10.1016/j.jaac.2021.08.021

8 Mathew, A., Saradamma, R., Krishnapillai, V., & Muthubeevi, S. B. (2021). Exploring the Family factors associated with Suicide Attempts among Adolescents and Young Adults: A Qualitative Study. Indian journal of psychological medicine, 43(2), 113–118. https://doi.org/10.1177/0253717620957113

9 Chopra, S. (2022, September 9). Black girls are experiencing record rates of self-injury and death by suicide. https://youthtoday.org/2022/09/black-girls-are-experiencing-record-rates-of-self-injury-and-death-by-suicide/

10 Langston, L. & Truman J.L. (2014)

11 Meza, J.L., Patel, K., Bath, E. (2022)

12 American Academy on Child and Adolescent Psychiatry. (2022) AACAP Policy Statement on Increased Suicide Among Black Youth in the US. https://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx

13 Langston, L. & Truman, J.L. (2014)

14 Bethune, S. (2022). Increased need for mental health care strains capacity. American Psychological Association (APA). https://www.apa.org/news/press/releases/2022/11/mental-health-care-strains

15 Okonofua, J. A., & Eberhardt, J. L. (2015). Two Strikes: Race and the Disciplining of Young Students. Psychological Science, 26(5), 617–624. https://doi.org/10.1177/0956797615570365

16 Okoya, Wenimo. (2022, March 30). The fight for Black Lives needs to happen in schools. The Hechinger Report. https://hechingerreport.org/opinion-the-fight-for-black-lives-needs-to-happen-in-schools/

17 Okonofua, J.A., & Eberhardt, J.L. (2015)

18 Ward, E. C., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing research, 62(3), 185–194. https://doi.org/10.1097/NNR.0b013e31827bf533

19 Meza, J.L., Patel, K., Bath, E. (2022)

20 Ibid.

21 Okonofua, J. A., & Eberhardt, J. L. (2015) Nguyen A. W. (2020). 

22 Bethune (2022)

23 Religion and Mental Health in Racial and Ethnic Minority Populations: A Review of the Literature. Innovation in aging, 4(5), https://doi.org/10.1093/geroni/igaa035

24 Ibid.

25 The Mental Health Liaison Group.(2023).  MHLG Letter of Support - Pursuing Equity in Mental Health Act 118th Congress. https://adaa.org/MHLG098402

26 Ibid.

27 Ibid.

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 

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

Hidden Anguish

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

Risk factors & Causes 

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

• Family history of psychiatric disorders

• Childhood trauma (abuse/adversity)

• Intelligence level

• Education

• Early conduct problems

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

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

• Hyperarousal

• Negative mood

• Anger/irritability

• Dissociation

• Avoidance

• Numbing

• Nightmares

• Intrusive thoughts

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

The Three-Step Theory 

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

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

2. Dispositional - Innate tolerance to death and pain. 

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

Suffering in Silence

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

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

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

Building Resilience 

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

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

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

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

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

Contributed by: Ananya Udyaver

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

References 

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

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

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

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

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

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

7 Ibid.

8 Ibid.

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

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

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

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

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

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

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

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

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