Mental Health and the Asian American Experience

Introduction

Historical Underpinnings

On paper, Asian Americans have the lowest official rates of mental illness, divorce, and juvenile delinquency out of any ethnic demographic in the U.S., as well as the lowest utilization of traditional mental health services.[1,2] At first glance, this might seem to demonstrate a true success story for Asian Americans: surveys of college students found a trend of beliefs that Asian Americans naturally have fewer mental health issues in comparison to their white counterparts.[3] However, this belief masks a sobering reality: female young adult Asian Americans in fact have the highest rate of suicide deaths of any racial and ethnic groups.[4] The façade of Asian American strength ignores many cultural factors hindering Asian Americans' disclosure and recognition of mental health conditions.

Cultural pressures against disclosure can be traced back to traditional norms within Asian motherlands as well as the pressures of coalescing into American culture and the subsequent model minority myth. Collectivist cultures within many Asian countries hold that mental health problems exist because of a lack of control, making it "shameful" to seek help through therapy rather than dealing in private.[5] In this sense, individuals' development of mental illness can be thought to result from a lack of proper guidance from their family members, reflecting badly on their familial honor and reputation.[6] Such pressures to restrain potentially disruptive and strong feelings can lead to low usage of support, withdrawal, denial, and even cutting off mentally ill family members.[7,8] 

Crossing the ocean to America, historical discrimination and the accruement of generational traumas in Asian immigrants have also contributed to nondisclosure–particularly in relation to the model minority myth. Despite the common view of Asian Americans as an "immigration success story," that vision of success ignores a history of oppression. Collectively, since immigrating to America, Asians have been "the victims of laws that have denied them the rights of citizenship, ownership of land, and marriage and that have even forced the internment of over 110,000 Japanese Americans."[9] Perhaps ironically, the development of that success story was rooted in Asian Americans' oppression: in the nineteenth century, when the first wave of Chinese immigrants came to work on American railroads, they were compared to their Black counterparts and "praised for a superior work ethic."[10] During World War II and Japanese internment, Asian Americans felt pressures to act as "model citizens" in order to reduce racist sentiments, culminating in a 1966 New York Times article titled "Success Story, Japanese Style."[11] The article contrasted Asian Americans with "problem minority groups" to portray them as "rising above the barriers of prejudice and discrimination" and a "success story of meritocracy," as a means of dismissing civil rights activists' claims about racism.[12] 

The Model Minority Myth: A Facade

Such an argument pastes a pretty façade over gaping problems. Asian Americans are not a monolith; the article's statements of a "higher median income" for Asian Americans ignores differences between higher income groups (for example, South and East Asians) and marginalized communities (for example, Southeast Asians) as well as the higher percentages of multiple wage earners in the family, equal incidence of poverty, and salaries not commensurate with educational levels of Asian American workers.[13,14] Besides heightening tensions with other minority groups, such a myth diverts attention from discrimination and prejudice against Asian Americans, and has even lowered research and policy interests in Asian American communities due to misconceptions that they do not require resources and support. The model minority myth ignores the historical xenophobia faced by Asian immigrants in America for centuries and now even today, with the current rise of anti-Asian hate during the COVID-19 pandemic.[15] 

The creation of this façade can result in a form of gaslighting against Asian Americans experiencing mental health issues; the positive light can cause people to claim that no problems are happening, with the belief that Asian Americans are "immune from cultural conflict and discrimination."[16,17] Because of the prevailing belief that Asian Americans do not experience mental health conditions to the same extent as other demographics, American society can be dismissive of disclosed stresses and issues. Asian American parents can often portray a mindset that their child is making a big deal out of nothing and are in denial that their child needs mental health counseling, perhaps demonstrating an internalization of the model minority myth.[18] 

The Pressure to Succeed

The parent-child relationship is in fact a key player in an Asian American child's experience with mental health, which is affected in large part by Asian cultural values and the model minority myth. Both influences place high expectations and high pressures on children to uphold familial honor and find a successful position in the "model minority" meritocracy. This pressure can adversely affect mental health: in a survey of Asian American children with mental health conditions, their largest reported source of stress was parental and societal pressures of high achievement.[19] The pressures exerted by the expectation of Asian success can compound with high parental expectations reinforcing the stereotype, making it difficult for children to reconcile these pressures and disregard the harmful stereotypes against Asian Americans.[20]

The high pressures of success placed on Asian American children–whether because of cultural tradition, parenting style, model minority myth, or a combination–are correlated with mental health difficulty. Asian American adolescents stereotyped as "academic overachievers" frequently experience serious mental health challenges, including higher social anxiety, lower self-esteem, and greater depressed mood and risk for self-injury.[21] Stemming from cultural values of familial honor and achievement as well as pressures of upward mobility in America, 28% of Asian American mothers and 19% of Asian American fathers can be described as a "tiger parent," whose harsh parenting styles coexist with warmth and attentiveness.[22] Although dependent on whether the child perceives this parenting as controlling or harsh, such disempowering parenting methods can be associated with anxiety, stress, depressive symptoms, and suicidal ideation in Asian American adolescents.[23] Parental emphases on "collectivism [and] interdependency," when operationalized with measures of meeting parental expectations for academic or career achievement, are found to be correlated with psychological distress in Asian American children.[24] 

Self-Stigma and Self-Concealment: Difficulty Seeking Help

The greater amounts of stress placed on Asian American children makes it all the more troubling that disclosure rates and utilization of mental health resources are lowest in this demographic. The fact that Asian Americans are less likely to seek help for their mental health makes them more likely to wait until they have developed severe somatic symptoms or even a crisis situation before they reach out for mental health support.[25-27] Self-stigma, an internalization of negative societal beliefs around mental health, is already prevalent in the general population, where negative images of mental illness lower individuals' internalized self-concept, self-esteem, and self-efficacy.[28] In this way, seeking help is internalized as a feeling of inferiority; over 75% of all respondents to a survey conducted by Vogel et al. (2006) said they would feel "less satisfied with [them]selves," "inadequate," or even "less intelligent" if they were to seek psychological help. 

Being Asian American heightens this stigma, with the model minority myth enforcing an idea of remaining silent about one's struggles, creating unresolved issues that build up stress.[29] In fact, Asian Americans have greater mental health stigma and less favorable help-seeking attitudes than European Americans.[30] Stemming from cultural contexts where "excessive self-disclosure and strong emotional expression" are seen as "disruptive acts against collective harmony and family honor," Asian American college students were found to display more self-concealment of potentially distressing personal information than were European Americans.[31] Such self-concealment was additionally negatively correlated with attitudes toward seeking psychological help. However, there is hope: another study found a significant correlation between previous experiences with counseling and "an increased willingness to seek such services in the future" as well as "higher ratings regarding severity of some problems, such as substance abuse."[32] Such an increase demonstrates the potential to counter Asian Americans' tendency to downplay the hardships they are enduring through receiving education that it is healthy rather than shameful to disclose struggles.

Possible Interventions

This finding leads us to a few potential interventions to combat Asian Americans' lack of disclosure regarding mental health conditions. Disseminating education around mental health in Asian American communities is an important step to cultivate healthy conversations between parents and children around mental health.[33,34] This education should highlight incremental preventative care for mental health to prevent further waiting until dire need or crisis to act. To be most effective, this education should also be tailored specifically to Asian American communities by using culturally familiar situations to normalize mental health conditions, medications, and therapy.[35] 

One specific intervention tested by Yang et al. (2013) was a process of stereotype disconfirmation in Asian American parents to aid their relationship with their children's mental health experiences. In this experiment, parents were given an opportunity to directly interact with a caregiver who would disconfirm pre-existing stereotypes and unhealthy reactions to their children in order to create healthier relationships and reactions to disclosure in families. For example, specific Chinese "tiger parenting" strategies like using criticism as motivation were countered by demonstrating how this method exacerbates mental health situations. The experiment was found to improve parents' reactions to their children's disclosure, which could help encourage more disclosure. In doing so, the parents reported an importance of seeing direct real-life application of their situation from a teacher who had similar lived experiences to them.

Finally, in the counseling field, we need to address barriers to cross-cultural counseling, which include culture-bound values, class-bound values, and language factors.[36] Because counseling strategies and techniques may force clients to oppose cultural values, particularly in Asian American patients who value restraint of strong feelings, we need to find ways to work within the bounds of culture or compassionately reason why cultural values can be harmful in order to build a healthy therapeutic relationship. By addressing the convergence of stereotypes, historical trauma, and cultural barriers to cross-cultural counseling, therapists can provide more empathetic support to Asian Americans in collaboratively confronting their mental health conditions.  

For more information, click here to access an interview with Psychologist Sarah Gaither on race & social identity.

Contributed by: Anna Kiesewetter

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

References

1 Sue, D. W. (1993, November 30). Asian-American mental health and help-seeking behavior: Comment on Solberg et al. (1994), Tata and Leong (1994), and Lin (1994). Journal of Counseling Psychology. Retrieved February 22, 2022, from https://eric.ed.gov/?id=EJ487581

2 Masuda, A., & Boone, M. S. (2011, September 21). Mental health stigma, self-concealment, and help-seeking attitudes among Asian American and European American college students with no help-seeking experience - International Journal for the Advancement of Counselling. SpringerLink. Retrieved February 23, 2022, from https://link.springer.com/article/10.1007/s10447-011-9129-1

3 Jung, S. (2021, June 18). The model minority myth on Asian Americans and its impact on mental health and the clinical setting. Asian American Research Journal. Retrieved February 22, 2022, from https://escholarship.org/uc/item/2g78c205  

4 Lee, S., Juon, et al. (2008, October 18). Model minority at risk: Expressed needs of Mental Health by asian american young adults - journal of community health. SpringerLink. Retrieved February 22, 2022, from https://link.springer.com/article/10.1007/s10900-008-9137-1  

5 Ibid.

6 Sue, 1993

7 Ibid.

8 Yang, L. H., et al. (2013, December 6). A brief anti-stigma intervention for ... - sage journals. PubMed. Retrieved February 22, 2022, from https://journals.sagepub.com/doi/full/10.1177/1363461513512015  

9 Sue, 1993

10 Yi, V. (2016, February 9). Model minority myth. The Wiley Blackwell Encyclopedia of Race, Ethnicity, and Nationalism. Retrieved February 22, 2022, from https://www.academia.edu/21743155/Model_Minority_Myth 

11 Ibid.

12 Ibid.

13 Sue, 1993

14 Yi, 2016

15 Canady, V. A. (2021, March 26). Field condemns hate‐fueled attacks of Asian Americans, offers MH supports. Wiley Online Library. Retrieved February 22, 2022, from https://onlinelibrary.wiley.com/doi/10.1002/mhw.32736 

16 Jung, 2021

17 Sue, 1993

18 Jung, 2021

19 Lee et al., 2008

20 Ibid.

21 Choi, Y., et al. (2019, December 16). Disempowering parenting and Mental Health Among Asian American Youth: Immigration and Ethnicity. Journal of Applied Developmental Psychology. Retrieved February 22, 2022, from https://www.sciencedirect.com/science/article/pii/S0193397319301145 

22 Ibid.

23 Ibid.

24 Ibid.

25 Lee et al., 2008

26 Jung, 2021

27 Sue, 1993

28 Vogel, D. L., et al. (2006). Measuring the self-stigma associated with seeking ... Measuring the Self-Stigma Associated With Seeking Psychological Help. Retrieved February 22, 2022, from https://selfstigma.psych.iastate.edu/wp-content/uploads/sites/204/2016/02/SSOSH_0.pdf 

29 Lee et al., 2008

30 Masuda & Boone, 2011

31 Ibid.

32 Sue, 1993

33 Lee et al., 2008

34 Sue, 1993

35 Yang et al., 2013

36 Sue, 1993

Pandemic's Toll on Mental Health

Introduction

Since January 20, 2020, the COVID-19 pandemic has proved to be a crisis that will impact the world for years to come. Although the pandemic has consistently been presented as a physical health crisis, its prolonged and uncertain effects have negatively impacted mental health, especially for vulnerable populations. This increased mental distress during the pandemic is occurring against already existing high rates of mental illness and substance use in the United States. The pandemic has led to isolation and occupational/academic shifts, which have already been established as stressors that make people especially vulnerable to mental health problems. The pandemic’s safety precautions (e.g., such as social distancing) have also imposed additional barriers in the help-seeking process for all individuals, both those who have just started to experience negative mental health and those whose mental health has gotten significantly worse. 

Systematic reviews have found an association between the pandemic and greater anxiety and depression in the general population, with more pronounced effects among specific demographic and minority groups. From April to June 2020, during one of the first peaks of the coronavirus pandemic, anxiety disorder and depressive disorder symptoms increased significantly in the United States when compared with the same months in 2019.[1,2] 

Anxiety during a pandemic is not surprising. The unpredictability of the coronavirus, paired with the fear of becoming infected with an unknown virus, elicits anxious symptoms. Continual news reports of increasing death tolls and infection rates further increase this anxiety. COVID-19 symptoms and anxiety symptoms overlap, with many similarities, and also impact each other, making the other worse. For instance, anxiety’s somatic symptoms, such as sweat and muscle pain, could be confused with COVID-19 symptoms, heightening fear and worry in the individual. 

There are increased mental health burdens associated with the pandemic; these burdens are disproportionately impacting groups that were already at heightened risk pre-pandemic, such as individuals with low socioeconomic status, racial/ethnic minorities, and sexual/gender minorities. One study comparing depressive symptom prevalence between pre- and post-pandemic times found that prevalence increased by three-fold throughout the pandemic, with greater risk observed among individuals with lower income and a greater number of pre-pandemic stressors.[3] A 2021 CDC report announced that the “percentage of adults with recent symptoms of an anxiety or depressive disorder increased significantly from 36.4% to 41.5%.”[4] This increase was most prominent for two groups of people: adults aged 18 to 29 years old and those with less than a high school education.[5]

Conversely, other studies indicate that Americans have shown resilience. A self-report study on 157,213 Americans found that anxiety increased initially in the first few months of the pandemic, but later returned to baseline.[6] However, sadness and depression continued to increase in later pandemic months, probably as residual effects of the increased uncertainty and worry in the early months of the outbreak. Despite these initial and persisting negative impacts, the present study, conducted by Yarrington et al., suggests that many Americans demonstrated resilience over the span of the pandemic in the United States.[7] 

Economic downturn: unemployment & income inequality

The COVID-19 pandemic was responsible for one of the worst economic recessions the United States had seen in years. These rapid changes to our economy created additional stressors, further striking the mental health of certain individuals. For instance, a review conducted under the Kaiser Family Foundation (KFF) compiled that adults experiencing unemployment reported higher rates of anxiety and depressive disorder compared to adults who didn’t experience job loss. The figure below shows this drastic difference in rates, with 53.4% of respondents who lost their jobs reporting symptoms, while only 32% of individuals who didn’t lose their jobs reporting the same symptoms.[8]

Anxiety and depression increases were not the only mental health consequences linked to the pandemic. Other outcomes included substance use disorder and suicidality. Previous research from earlier economic downturns has consistently found that job loss is associated with increased depression, anxiety, distress, and low self-esteem, all of which lead to a higher risk for substance use disorder and suicidality. For example, the 2008 to 2010 economic crisis was correlated with an additional 10,000 suicides in Europe and North America.[9] The same KFF review above found that when compared to households experiencing no income decreases or unemployment, households that did experience these disturbances reported higher rates of pandemic-related worry or stress, resulting in significant decreases in their mental health and well-being. Some of these developments included difficulty eating and sleeping, increases in alcohol abuse and substance use, and worsening pre-existing chronic conditions.[10]

A negative correlation has been found between annual income and the susceptibility of developing mental health disorders due to the pandemic. Households with lower incomes were more likely to report major negative mental health outcomes throughout the pandemic. One of the KFF tracking polls observed that 35% of those earning less than $40,000 reported experiencing at least one adverse mental health outcome, while only 21% of those who earned between $40,000 to $89,000 and 17% of those earning $90,000 or more reported the same.[11]

BIPOC community

Not only has the COVID-19 pandemic disproportionately impacted the BIPOC (Black, Indigenous, and People of Color) community in terms of death and infection rates, but they have also been more likely to report a greater number of adverse mental health effects.  Due to longstanding systemic and institutional inequities, BIPOC individuals are already at a heightened risk for a multitude of conditions that make them more vulnerable to poorer physical and mental health, such as low socioeconomic status, lack of access to healthcare and education, and greater job instability. For example, BIPOC individuals already constitute an overrepresentation in essential jobs (e.g., the transportation sector, where socially distancing is more difficult) they are therefore more susceptible to COVID-19 transmission and subsequent negative mental health effects. 

Even before the pandemic, BIPOC groups were already at a magnified risk for mental health disorders due to the pronounced lack of access to mental health care services. Historically, these communities of color have faced marked challenges accessing mental health care. The scarcity of culturally-adapted evidence-based treatments, as well as low minority representation within the field, impose barriers to the therapeutic alliance, increasing the likelihood of People of Color avoiding and dropping out of therapy. The pandemic has only further increased this gap in mental health problems and access. 

Below is a figure breaking down the mental health impact the pandemic has had on different racial/ethnic groups. As the figure demonstrates, non-Hispanic Blacks and Hispanics/Latinos are at the top of the breakdown, with 46% to 48% reporting anxious or depressive symptoms, a significantly higher proportion compared to the 40.9% share in the non-Hispanic White sample.[12]

Although African Americans make up only 13% of the United States population, they have comprised 30% of COVID-19 patients (whose race was known) and 34% of COVID-19 deaths in 29 states.[13] The CDC compared the risk for COVID-19 hospitalization and death between racial/ethnic minority groups and White individuals. They found that African Americans were 2.5 times more likely to be hospitalized and 1.7 times more likely to die.[14] Likewise, Latinos were 2.4 times and 1.9 times more likely, respectively.[15]

Moreover, the intersection of race and socioeconomic status magnifies these impediments. Most of the safety precautions that individuals could take during a pandemic, like hand-washing and social distancing, are “functions of privilege”.[16] Andoh (2020) notes that a likely factor contributing to the disproportionate rates of infection and deaths is that People of Color are more likely to live in racialized and impoverished neighborhoods, with limited or no access to sanitation and health care.[17]

Throughout the pandemic, Asian Americans have been the targets of raging xenophobia throughout the United States. Negative stereotypical language about the COVID-19 pandemic, such as “Chinese virus” and “Kung flu”, increased rates of anti-Asian discrimination in the United States. Racial trauma, which occurs as a result of microaggressions, discrimination, and racism, negatively impacts the mental health of targeted groups. These discriminatory and racist thoughts and acts have been found to contribute to poorer health and increased rates of chronic health illnesses.[18,19] A 2015 meta-analysis on racism and mental health found that racism was significantly correlated with poorer mental health, such as anxiety, depression, and psychological stress.[20]

Essential workers

Essential workers were and continue to be the backbone of the United States economy during the COVID-19 pandemic. Specifically, grocery, healthcare, package, and delivery employees are at a heightened risk of contracting COVID-19. Additionally, these workers are at a heightened risk of developing symptoms of depression and anxiety. Significantly more essential workers reported these symptoms than non-essential workers (42% to 30%).[21] In addition, 25% of essential workers reported starting or increasing substance abuse and 22% of them reported suicidal ideation, while only 11% and 8% of non-essential workers reported the same, respectively.[22] The figure below visually depicts these contrasts.

School-aged children & their parents 

To prevent further COVID-19 spread, schools at all grade levels shut down at a nationwide level and transitioned to online learning in 2020. These school closures disrupted families’ routines and dynamics, especially through the sudden lack of childcare, as many working parents depend on schools as a form of daycare. Children were also deprived of a major source of human contact and knowledge, a developmental necessity. As developmental psychologists have argued, children need interactions with people outside of their immediate family network (e.g., teachers and peers) in order to develop accordingly and healthily. A 2018 comprehensive review on the role several macro- and micro-contexts have on child development, “Early care and education settings are, next to the family, the most important social contexts in which early development unfolds”.[23] Teachers can serve as protective factors, instilling motivation and providing psychological support.[24] In-person schools have the capacity to not only facilitate the attainment of concrete knowledge but also enhance social and emotional competencies.[25] The shift to remote learning for prolonged periods of time significantly impacted the well-being of school-aged children. A study with a representative sample of primary and secondary Chinese students found that the three most prevalent symptoms were anxiety (24.9%), depression (19.7%), and stress (15.2%).[26] A protective factor was parent-child discussion, characterized as the amount of pandemic-related discussion between the child and their parent(s).[27]

Not only are parents concerned about their childrens’ well-being, but parents are also at heightened risk of negative mental health outcomes. This effect was also found to occur differentially based on gender in heterosexual relationships, with mothers being more likely to report these outcomes than fathers. The figure below shows this differing impact.[28] Pre-pandemic, women were already more likely than men to report decreased mental health. The pandemic has only further escalated this gender difference. 

The mental well-being of parents and children affected each other bidirectionally, with high paternal stress correlated with worsened mental health in children, and worsened mental health in children correlated with decreased parental well-being. A national survey on the well-being of parents and children throughout the COVID-19 pandemic found that higher rates of poor mental health for parents simultaneously occurred with deteriorating behavioral health for children in approximately 1 in 10 families.[29] Among these families, 48% reported loss of child care, 16% reported change in insurance status, and 11% reported worsening food security.[30]

Adolescents and young adults

Adolescence and young adulthood are critical developmental periods characterized by an increase in independence, often by starting college, moving out of one’s childhood home, exploring more serious romantic relationships, and entering the workforce. Yet, the pandemic and its accompanying restrictions have put a halt to these milestones. For young people, the disruptions to access to mental health services, school closures, and employment crises have most prominently impacted their well-being. 

Though initially one of the most low-risk groups for COVID-19 infection and death at the start of the pandemic, adolescents and young adults could arguably be the demographic whose mental health has been most negatively impacted. This disproportionate effect can be traced to the pandemic’s role on diminished, and even nonexistent, social relationships and a weakened sense of belonging. Young adults, with all the changes they undergo during this developmental period, are a high-risk group for loneliness, to begin with. Fluctuating social networks and a greater sense of independence away from the family unit predispose this population to higher levels of loneliness. Add onto that the social distancing and lockdowns associated with the pandemic, and an already potentially lonely demographic is now even less connected to others. To make matters worse, although mental health illness increased among this demographic, support stayed stagnant. 

According to a report sponsored by the Organisation for Economic Co-operation and Development, young people (15 to 24-year-olds) were 30% to 80% more likely to report symptoms of depression or anxiety than adults in Belgium, France, and the United States in March 2021; additionally, they also reported higher levels of loneliness.[31] Despite the slow return to “normal” and reopening of society, the prevalence of anxious and depressive symptoms among young people remains higher than pre-pandemic levels, demonstrating the pandemic’s significant leftover effects. 

Among college students specifically, multiple studies have found that over 70% have reported increases in stress, anxiety, and depression. Most students attribute these increases to worries about the health of themselves and loved ones (91%), deficits in concentration (89%), sleep disruptions (86%), decreases in belongingness and social interactions (86%), and academic performance worries (82%).[32] College students have adopted a variety of coping mechanisms, both positive and negative. These include support from family and friends, exercise, meditation, and new hobbies, to increases in alcohol and drug consumption, and procrastination.[33]

Sexual and gender minorities 

When compared to heterosexual and cisgender populations, sexual and gender minorities experience greater health disparities. These pre-existing mental health incongruities have made them particularly vulnerable during a time like the COVID-19 pandemic. According to a review by the American Psychological Association (APA), these groups reported notably higher rates of alcoholism, substance abuse, PTSD, depression, anxiety, OCD, and suicidal behaviors throughout the pandemic.[34]

Sexual and gender minorities experience paramount barriers to medical care, both physical and mental. The lack of culturally competent, respectful, and accepting healthcare providers elicits medical distrust and avoidance. Baumann et al. (2020) note that queer and trans individuals were already more likely to be homeless or lack access to resources pre-pandemic.[35] The COVID-19 pandemic has only exacerbated these inequities. For queer youth, in particular, pandemic-related school closures may have severed access to potential support structures outside of the home, such as peers, school clubs/organizations, and school counselors. This community-building, a well-known resilience factor for sexual and gender minorities, was hindered by COVID’s social distancing and stay-at-home policies. 

A KFF tracking poll attempting to examine the pandemic’s impact on LGBT (lesbian, gay, bisexual, transgender) individuals found that almost three-fourths (74%) say worry and stress from the pandemic has harmed their mental health.[36] Conversely, only 49% of respondents who are not LGBT, reported the same.[37] Another study conducted by Moore et al. (2021) found that the LGBT population had significantly higher rates of pandemic-related depression and anxiety symptoms, often surpassing clinical concern thresholds.[38]

What the mental health field can do to mitigate these disproportionate outcomes 

It is important to note that all the demographics listed above do not exist in isolation. Many individuals identify under multiple categories, such as African-American mothers, Asian American college students, or a low-income and transgender essential worker. When there are multiple avenues of oppression and disadvantage, all of the negative impacts listed above are intensified. To combat these intersectional inequities and aid marginalized communities, the APA recommends that psychologists “understand their place, be a partner (not a savior), encourage the use of bystander intervention, and be an advocate.”[39]

Psychologists must recognize their own biases and privilege. Exhibiting cultural competence and humility, and actively committing to anti-racist practices, are essential components for effectively addressing and treating the ill-proportioned mental health struggles of minority populations. The APA loosely defines cultural competence as, “the ability to understand, appreciate and interact with people from cultures or belief systems different from one's own.”[40] Before the lack of minority representation in the mental healthcare field can be tackled, which is due to a variety of deep-rooted issues, current providers should be equipped with cultural competence and anti-racist guidelines. Evidence-based treatments (EBTs), and the field of psychological science as a whole, has a long history of ignoring minority groups by only studying WEIRD samples (Western, Educated, Industrialized, Rich, and Democratic). Therefore, cultural adaptations to existing EBTs are crucial for equity in care. Meta-analyses conducted on the efficacy of these modified EBTs have concluded that they are widely effective for marginalized groups.[41]

Cultural humility is an added factor to cultural competence. It shifts this knowledge-based stance to a lifelong learning process. One must also account for within-cultural variation. For example, although Latinx is one categorical division, there are actually 33 countries throughout Latin America and the Caribbean, each with unique histories and traditions. Additionally, Latinx individuals born in the United States encounter very different life trajectories and events compared to their immigrant counterparts. Therefore, achieving a balance between gaining knowledge while also recognizing and prioritizing individual differences is crucial. 

An example of these cultural considerations is the Cultural Formulation Interview, which is a semi-structured interview to elicit a client’s racial identification and cultural background. The salience of identities varies by client. Although a therapist can have two clients that identify as Latina women, one of them may prioritize their womanhood more, while the other may prioritize their latinidad (Latinx ethnicity) more. The questions within this interview guideline allow therapists to gauge the importance and hierarchies that clients have about their identities and culture. The mere process of asking these types of questions strengthens the therapeutic alliance because it demonstrates care to clients. Through this strengthening, one of the main barriers that minorities experience, lack of a connection with their therapist and subsequent dropout, is prevented. It is key to remember that there is no end goal when learning about the history and struggles of marginalized communities. Thus, providers must follow the client’s lead and view cultural competence as a continual learning process which will benefit society throughout the pandemic and beyond.

For more information, click here to access an interview with Psychiatrist David Neubauer on insomnia & anxiety.

Contributed by: Nicole Izquierdo

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

References

1 CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

2 CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January–June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERmentalhealth-508.pdf

3 ​​Ettman, C. K., Abdalla, S. M., Cohen, G. H., Sampson, L., Vivier, P. M., & Galea, S. (2020). Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. JAMA Network Open, 3(9), e2019686–e2019686. https://doi.org/10.1001/jamanetworkopen.2020.19686

4 Vahratian A, Blumberg SJ, Terlizzi EP, Schiller JS. Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic — United States, August 2020–February 2021. MMWR Morb Mortal Wkly Rep 2021;70:490–494. DOI: http://dx.doi.org/10.15585/mmwr.mm7013e2

5 Ibid. 

6 Yarrington, J. S., Lasser, J., Garcia, D., Vargas, J. H., Couto, D. D., Marafon, T., Craske, M. 

G., & Niles, A. N. (2021). Impact of the COVID-19 Pandemic on Mental Health among 157,213 Americans. Journal of affective disorders, 286, 64–70 

https://doi.org/10.1016/j.jad.2021.02.056

7 Ibid.

8 Panchal, N., Kamal, R., Cox, C., & Garfield, R. (2021, February 10). The Implications of COVID-19 for Mental Health and Substance Use. KFF. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/

9 Reeves, A., McKee, M., & Stuckler, D. (2014). Economic suicides in the Great Recession in Europe and North America. The British Journal of Psychiatry: The Journal of Mental Science, 205(3), 246–247. https://doi.org/10.1192/bjp.bp.114.144766

10 Panchal, N., Kamal, R., Cox, C., & Garfield, R. (2021). KFF. 

11 Ibid.

12 Ibid.

13 Andoh, E. (2020, May 1). How psychologists can combat the racial inequities of the COVID-19 crisis in American Psychological Association. Retrieved February 28, 2022, from https://www.apa.org/topics/covid-19/racial-inequities

14 CDC. (2022, February 1). Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

15 Ibid.

16 Andoh, E. (2020). 

17 Ibid.

18 Williams, D.R., Lawrence, J.A., Davis, B.A. & Vu, C. (2019). Understanding how discrimination can affect health. Health Services Research, 54 (S2), 1374-1388. https://doi.org/10.1111/1475-6773.13222

19 Williams, D.R. & Mohammed, S.A. (2013). Racism and health I: Pathways and scientific evidence. American Behavioral Scientist, 57, 1152-1173. https://doi.org/10.1177/0002764213487340

20 Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLOS ONE, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

21 Panchal, N., Kamal, R., Cox, C., & Garfield, R. (2021). KFF.

22 Ibid.

23 Osher, D., Cantor, P., Berg, J., Steyer, L., & Rose, T. (2020, January 24). Drivers of human development: How relationships and context shape learning and development. Applied Developmental Science, 24:1, 6-36. 10.1080/10888691.2017.1398650

24 Ibid.

25 Flook, L. (2019). Four Ways Schools Can Support the Whole Child. Greater Good. https://greatergood.berkeley.edu/article/item/four_ways_schools_can_support_the_whole_child

26 Tang, S., Xiang, M., Cheung, T., & Xiang, Y.-T. (2021). Mental health and its correlates among children and adolescents during COVID-19 school closure: The importance of parent-child discussion. Journal of Affective Disorders, 279, 353–360. https://doi.org/10.1016/j.jad.2020.10.016

27 Ibid.

28 Panchal, N., Kamal, R., Cox, C., & Garfield, R. (2021). KFF. 

29 Patrick, S. W., Henkhaus, L. E., Zickafoose, J. S., Lovell, K., Halvorson, A., Loch, S., Letterie, M., & Davis, M. M. (2020). Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey. Pediatrics, 146(4), e2020016824. https://doi.org/10.1542/peds.2020-016824

30 Ibid.

31 Takino, S., Hewlett, E., Nishina, Y., & Prinz C. (2021, May 12). Supporting young people’s mental health through the COVID-19 crisis. Organisation for Economic Co-operation and Development. Retrieved February 28, 2022, from https://read.oecd-ilibrary.org/view/?ref=1094_1094452-vvnq8dqm9u&title=Supporting-young-people-s-mental-health-through-the-COVID-19-crisis

32 Son, C., Hegde, S., Smith, A., Wang, X., & Sasangohar, F. (2020, March 9). Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study J Med Internet Res 2020; 22(9): 21279. https://doi.org/10.2196/21279

33 Ibid. 

34 Baumann, E., Kishore, A., Page, K., Ryu, D., Skinta, M., & Wagner, K. (2020, June 29). How COVID-19 impacts sexual and gender minorities in American Psychological Association. Retrieved February 25, 2022, from https://www.apa.org/topics/covid-19/sexual-gender-minorities

35 Ibid.

36 Dawson, L., Kirzinger, A., & Kates, J. (2021, March 11). The Impact of the COVID-19 Pandemic on LGBT People. KFF. https://www.kff.org/coronavirus-covid-19/poll-finding/the-impact-of-the-covid-19-pandemic-on-lgbt-people/

37 Ibid.

38 Moore, S. E., Wierenga, K. L., Prince, D. M., Gillani, B., & Mintz, L. J. (2021). Disproportionate Impact of the COVID-19 Pandemic on Perceived Social Support, Mental Health and Somatic Symptoms in Sexual and Gender Minority Populations. Journal of Homosexuality, 68(4), 577–591. https://doi.org/10.1080/00918369.2020.1868184

39 Andoh, E. (2020). 

40 Deangelis, A. (2015, March). In search of cultural competence. American Psychological Association. Vol 46, No. 3. Retrieved February 28, 2022, from https://www.apa.org/monitor/2015/03/cultural-competence

41 Ibid.

The Impact of Nervous System Attunement on Social Anxiety

Understanding Social Anxiety

There is a growing body of research elucidating the scientific complexity of communication and information between people in a social context.[1] Neurons transmit information throughout one’s body, but our whole selves interact with the whole selves of other people, as well. Mirror neurons are one key way in which we empathize and connect with others in social situations, and are fundamental to interpersonal connection. In The Whole Therapist podcast, psychotherapists Abby Esquivel and Kellee Clark discuss the importance of mirror neurons and explain that, “When we stick our tongue out to a baby and the baby’s at a developmental age where they stick their tongue out back at us, they’re mirroring what we just did. Those are the mirror neurons firing. And when they fire, they wire together.”[2] In addition to empathy, mirror neurons have also been shown to be involved in understanding the intentions of others.[3,4] The role of mirror neurons is relevant to the discussion of social anxiety, as they can serve as a way of spreading safety to others, while the regulation of our own physiology can signal safety to ourselves. 

Social anxiety is most-common among 18-29 year-olds and about 12.1% of U.S. adults experience social anxiety disorder at some point in their lives. While 31.3% of sufferers experience only mild severity of symptoms, 38.8% report moderate severity, and 29.9% fit into the serious severity category.[5] This disorder can cause significant impairment in daily functioning, especially for those who live in societies that demand regular interaction with others. Not only can it interfere with daily chores like talking to cashiers at the grocery store, but it can hinder participation in class or collaboration in the workplace, prevent people from initiating conversations, and inhibit cultivation of deeper friendships or romantic relationships. 

Social anxiety is experienced as a persistent fear about how one is being perceived.[6] This type of anxiety can be distressing during a social interaction, as well as before and after. People who suffer from social anxiety might try and control others’ perceptions of them by altering their behavior toward what they think is a more desirable way of being. According to Goldin, et al. (2009), people with social anxiety have less neural activation associated with cognitive regulation related to social threat stimuli.[7] In other words, people with social anxiety may struggle to regulate when they feel threatened. Due to neuroplasticity research, we know that brains change and re-shape constantly, which provides hope for those who feel chronically socially anxious.[8,9] If people with social anxiety can introduce a feeling of safety when they ordinarily feel threatened, over time their brains may adapt to react less fearfully in similar contexts. Due to the fact that we simply cannot control or ever know what goes on inside other people’s heads, there is scant evidence in the moment if we have achieved the perspective we seek. Even if others view us favorably in the moment, stress can persist about maintaining that positive regard. Therefore, we must shift our energy away from trying to control others’ perceptions and focus more on the internal responses that occur within our bodies when a threat is registered. 

Symptoms

Figure 1

Note: This figure was based on a chart produced by Trudeau, K. (2020). [10] 

Rehearsal and role-play, exposure treatments, and cognitive behavioral therapy all serve as common psychotherapeutic treatments for social anxiety. SSRIs, MAOIs, and Benzodiazepines are medications that may provide relief as well.[11] However, one type of intervention that can be implemented immediately and without professional supervision is the attunement to one’s own nervous system. Our nervous systems guide our behavior.[12] Whether we are in fight, flight, freeze, or a state of safety, the way in which we interact and function will look different depending on which state we’re in. For instance, if someone has anxiety about driving, when they merge on the freeway they may experience tunnel vision, increased blood pressure, increased muscle tension, a release of stress hormones, and be distracted and irritable to others in the car.[13] Alternatively, if one is in a state of safety when checking out at the grocery store, they may take their time bagging their food and chat with the cashier. Or, they might decide not to engage in conversation with the employee, but remain calm in the absence of discussion. Someone with social anxiety may experience rapid thoughts in the silence or a subtle tightness in their shoulders as they wonder whether they should say something. By tuning into one’s nervous system, it is possible to determine whether one is in fight-or-flight mode and then carry out an exercise to shift into a state of safety. Gaining this awareness can help with emotional regulation by following up with breathing and muscle relaxation strategies.

Neuroscientist Stephen Porges developed Polyvagal Theory (1994) to explain the relationship between the nervous system and human behavior. This theory postulates that our bodies constantly scan and survey our environments, registering different stimuli as safe or threatening.[14] When safety is detected, the parasympathetic nervous system engages; when threatening stimuli are detected, the sympathetic nervous system engages. When the latter system activates, our bodies automatically release stress hormones, heart rates increase, and digestion slows to prepare us to fight or flee for survival.[15] Through mirror neurons, when we self-regulate through intentional physiological relaxation, it is likely that we will communicate more calmness and safety subconsciously through tone of voice, posture, and gestures.[16] Not only will this decrease the felt experience of social anxiety within oneself, but there is an added benefit of spreading calmness and openness to those we are interacting with. We therefore can spread safety to others through attuning to ourselves.

By manually regulating our nervous system through mindful awareness and muscle relaxation techniques, we can train our bodies to realize that socializing is not threatening.[17,18] The repetition of this practice can eventually lead to quicker parasympathetic (rest) responses and decrease the intensity of socially-activated anxiety. Further, since social anxiety is widely experienced as the fear of rejection, it may be comforting to consider that there is a smaller likelihood of being rejected if one comes across as emotionally stable, confident, and open-minded.[19] Even if one can’t achieve a certain image of perfection in another’s mind, people remember most vividly how they felt during an experience--  including social interactions. Making others feel comfortable and safe through one’s own authenticity and comfortability can lead to trust building as well as positive regard, which is potentially helpful for the rational part of the socially anxious mind. However, the point of this article is not to encourage or reinforce the tendency or desire to control others’ perceptions about oneself. Ultimately, the only control we have is over how much we practice mindful awareness of physical sensations during an anxious moment and then intervening with the following techniques:

Paced Breathing for Nervous System Relaxation

Breathing is one simple, yet powerful, way to move our systems out of a state of fight-or-flight. Inhaling activates the sympathetic nervous system (fight-or-flight), while exhaling activates the parasympathetic nervous system (rest and digest).[20] Therefore, there is an important caveat to be aware of when taking a deep breath: to effectively calm down, the exhale should be longer than the inhale. One exercise to try is breathing in for 4 counts, holding the breath for 7 counts, and exhaling for 8 counts. Any variation on these numbers should still elicit a calming response if the exhale is noticeably longer than the inhale.[21] 

Figure 2

Note: This figure was produced by Reddy, S. (2021).[22] 

Muscle Relaxation for the Nervous System

Mindfulness of the physical body is the other critical piece of tuning into one’s nervous system.[23] Catching oneself feeling socially anxious is ideal, because one can then question: what areas of my body are tense right now? First, just notice if the shoulders, jaw, stomach, or any other area are carrying tension. Exhaling, while releasing tension in those body parts, signals safety and relaxation to the brain. This exercise can be used during a social interaction, as well as when one is alone and feeling anxiety. Both of these methods serve as ways of “hijacking” the autonomic nervous system and reducing the automatic fight-or-flight response that happens when threat and danger are subconsciously detected.

Figure 3

Note: This figure was produced by Innovasium Cam’s Kids [24]

The goal is not to be calm all the time, because stress and anxiety are important and adaptive feelings that provide necessary information about our environments. Rather, the goal is to have a flexible nervous system that can smoothly flow into a state of fight-or-flight when there is a real threat and then back to a state of safety when one is not in danger. In moments where a threat is registered by the nervous system but one knows that they are actually safe, moving the body out of a physiological panic response can 1) be rapidly calming, 2) help rewire neural associations between safety and socializing, and 3) communicate safety and openness to others. Due to mirror neurons, when we can regulate and calm our systems, other people can also pick up on that safety and regulation and feel more receptive, open, and secure. This can serve as an incentive to practice mindfulness of one’s nervous system, because effective communication usually occurs when people feel safe. 

Dr. Fallon Goodman, researcher of social anxiety at University of San Francisco, says that we must foster social courage “knowing that rejection lurks right around the corner.” Furthermore, Goodman says to “Pursue experiences knowing that the chances of rejection are not zero. In fact, the chances that you get rejected at some point in your life-- at some point this year-- are high.” We must pursue the things that are meaningful to us and remember that the successes of those pursuits do not determine our worth as human beings.[25] 

For more information, click here to access an interview with Psychologist Kevin Chapman on panic & social anxiety.

Additionally, you may click here to access an interview with Venerable Thubten Chodron on meditation & anxiety.

Contributed by: Maya Hsu

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

References

1 Clark-Polner, E. & Clark, M. (2014). Understanding and accounting for relational context is critical for social neuroscience. Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2014.00127

2 Esquivel, A. & Clark, K. (Hosts). (2020-present). The Whole Therapist [Audio podcast]. Be and Belong Counseling PLLC. https://beandbelongcounseling.com/the-whole-therapist/

3 Iriki A. (2006). The neural origins and implications of imitation, mirror neurons and tool use. Curr. Opin. Neurobiol. 16, 660–667. 10.1016/j.conb.2006.10.008 

4 Iacoboni, M., Molnar-Szakacs, I., Gallese, V., Buccino, G., Mazziotta, J. C., & Rizzolatti, G. (2005). Grasping the intentions of others with one's own mirror neuron system. PLoS Biology, 3(3). https://doi.org/10.1371/journal.pbio.0030079 

5 U.S. Department of Health and Human Services. (n.d.). Social anxiety disorder. National Institute of Mental Health. Retrieved February 16, 2022, from https://www.nimh.nih.gov/health/statistics/social-anxiety-disorder 

6 DSM-5 definition of social anxiety disorder. DSM-IV-R Definition of Social Anxiety Disorder | Social Anxiety Institute. (n.d.). Retrieved February 16, 2022, from https://socialanxietyinstitute.org/dsm-definition-social-anxiety-disorder 

7 Goldin, P. R., Manber, T., Hakimi, S., Canli, T., & Gross, J. J. (2009). Neural bases of social anxiety disorder. Archives of General Psychiatry, 66(2), 170. https://doi.org/10.1001/archgenpsychiatry.2008.525 

8 Guimarães, D., Valério-Gomes, B., & Lent, R. (2020). Neuroplasticity: The brain changes over time! Frontiers for Young Minds. doi: 10.3389/frym.2020.522413

9 Gutchess, A. (2014). Plasticity of the aging brain: new directions in cognitive neuroscience. National Library of Medicine 346(6209). doi: 10.1126/science.1254604.

10 Trudeau, K. (2020). How to tell if you have a social anxiety disorder. Next Step 2 Mental Health. Retrieved February 16, 2022, from https://www.nextstep.doctor/how-to-tell-if-you-have-a-social-anxiety-disorder/ 

11 Behera, N., Samantaray, N., Kar, N., Nayak, M., & Chaudhury, S. (2020). Effectiveness of cognitive behavioral therapy on Social Anxiety Disorder: A comparative study. Industrial Psychiatry Journal, 29(1), 76. https://doi.org/10.4103/ipj.ipj_2_20 

12 National Academy Press. (1989). The Nervous System and Behavior. In Opportunities in Biology. 

13 Lanese, N. & Dutfield, S. (2022). Fight or flight: The sympathetic nervous system. LiveScience. https://www.livescience.com/65446-sympathetic-nervous-system.html 

14 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. W W Norton & Co.

15 Feiner-Homer, K. (2016). Generating therapeutic attunement through mindfulness practice. SOPHIA. Retrieved February 16, 2022, from https://sophia.stkate.edu/msw_papers/579/?utm_source=sophia.stkate.edu%2Fmsw_papers%2F579&utm_medium=PDF&utm_campaign=PDFCoverPages 

16 Cerdán, A. G. (2022). Mirror neurons: The most powerful tool. learn everything they can do. CogniFit. Retrieved February 16, 2022, from https://blog.cognifit.com/en/mirror-neurons/ 

17 Nidich S. et al. A randomized controlled trial of the effects of transcendental meditation on quality of life in older breast cancer patients. Integr Cancer Ther. 2009 Sep;8(3):228-34.

18 Lee, M. (2009). Calming your nerves and your heart through meditation. Science in the News. Retrieved February 16, 2022, from https://sitn.hms.harvard.edu/flash/2009/issue61/ 

19 Krzyzaniak, S. (n.d.). Top 10 Personality Traits of Likable People. Ready Set Psych! Retrieved from https://readysetpsych.com/top-10-traits-of-likable-people/ 

20 André, C. (2019, January 15). Proper breathing brings better health. Scientific American. Retrieved February 16, 2022, from https://www.scientificamerican.com/article/proper-breathing-brings-better-health/ 

21 Bergland, C. (2019). Longer exhalations are an easy way to hack your vagus nerve. Psychology Today. Retrieved February 16, 2022, from https://www.psychologytoday.com/us/blog/the-athletes-way/201905/longer-exhalations-are-easy-way-hack-your-vagus-nerve 

22 Reddy, S. (2021). Breathing techniques for stress and anxiety. SWAA. Retrieved February 16, 2022, from https://swaafrica.org/breathing-techniques-for-stress-and-anxiety/ 

23 Lazaro, R. (2020). Progressive muscle relaxation. Progressive Muscle Relaxation - an overview . Retrieved February 16, 2022, from https://www.sciencedirect.com/topics/medicine-and-dentistry/progressive-muscle-relaxation 

24 Tips and tools: Progressive muscle relaxation technique. Cam's Kids. (n.d.). Retrieved February 16, 2022, from https://www.camskids.com/tipsandtools/progressive-muscle-relaxation-technique/ 

25 Goodman, F. (2021). Social Anxiety in the Modern World. TEDx Talks. Retrieved from https://www.youtube.com/watch?v=EFhP4wP1TzU&ab_channel=TEDxTalks

Understanding Burnout: Does Zoom Make It Worse?

Source: Canva

What, Exactly, is Burnout?

Burnout is a psychological symptom that results from chronic work-related stress (Melamed et al., 2006). Melamed et al. define burnout simply as “emotional exhaustion, physical fatigue, and cognitive weariness.”[1] Specifically, Maslach et al. find that burnout can be conceptualized along three dimensions:[2,3] 

1. Exhaustion - stress and chronic fatigue due to overwhelming demands.

2. Cynicism - apathy, loss of interest in work, and a sense of futility and meaninglessness toward one’s job.

3. A decrease in quality of work performance - the manifestation of reduced feelings of performance-effectiveness or accomplishment

The multivariate impact of burnout is quantifiable. Burnout negatively impacts productivity and can be measured by: quantity of sick leave days, job retention, and the intention to change jobs.[4] Studies have also found higher levels of burnout have correlated with increased inflammation biomarkers, risk of cardiovascular disease, sleep disturbances, fatigue, and mood disturbances.[5-8]

How Does Burnout Arise?

In addition to more obvious factors like an overwhelming workload, two decades of research on burnout have illuminated some lesser known factors that influence one’s likelihood of burning out. If people perceive that they have the capacity to influence decisions within their workplace and believe they have access to resources necessary to perform well, job engagement is likely to increase. When people feel insufficient recognition or reward (i.e. financial, social, institutional) for their work, both they (as individuals) and their work can feel devalued; this is found to be closely related to feelings of inefficacy and decreased satisfaction. Interpersonal dynamics within the workplace also affect one’s experience of burnout; relationships characterized by support and trust protect against burnout, while unresolved conflict and a lack of trust between peers or coworkers are correlated with greater burnout risk. Fair and equitable policies are also important, as people who feel that they are not being appropriately respected can become chronically cynical, angry, or hostile. Finally, a conflict of values between an individual and their organization can increase one’s likelihood of developing burnout, as the continual pressure to make trade-offs between their values and obligations can affect stress and exhaustion levels.[9]

Figure 1: List of possible burnout symptoms

Image based on a list produced by Schaufeli & Enzmann (1998) [10]

Who Burns Out the Quickest?

Different individuals working under the same job conditions will not necessarily feel burned out at the same time or to the same degree. This is because burnout is a response to stress and individuals evaluate, cope with, and respond to stressors differently. One study by Ghorpade et al. (2007) finds that differences in personality can influence whether one conserves resources (consequently protecting themselves) or becomes susceptible to stressors. Further, extroversion and emotional stability have been found to be negatively related to emotional exhaustion.[11] Openness and agreeableness are also negatively correlated with burnout, while conscientiousness and neuroticism appear to be positively associated.[12,13] 

Something that researchers have struggled to account for is how often burnout might be mislabeled as depression or anxiety, and how such misdiagnoses can lead to ineffective treatment interventions. People suffering from burnout might appear to be depressed, as the symptoms of burnout resemble those of depression (e.g. loss of interest, fatigue, impaired concentration, depressed mood).[14] As there are no diagnostic criteria for burnout and it is not mentioned in the DSM-5, one cannot be formally diagnosed with the condition. One major distinction between depression and burnout is that burnout arises specifically in work-related contexts whereas depression is pervasive across different contexts.[15]

Burnout from Online and Telecommunication-Based Environments

It is often contended that screen time is associated with copious amounts of stress-related symptoms, including psychological, cognitive, and muscular impairments.[16,17] Mheidly et al. (2020) write that pandemics “are often associated with a state of stress and panic. Accordingly, strain resulting from telecommunication can accumulate with other stressors to lead to exhaustion, anxiety, and burnout.”[18] They note that imposed lockdowns, quarantines, and the inability to socialize as a result of the COVID-19 pandemic have led to considerable disruptions in lives, often accompanied by increased tension, anxiety, boredom, and disturbed sleep cycles. Within workplaces, promotions have been delayed and wages have been cut; these negative changes can create adverse levels of pressure and anxiety within people.

Mheidly et al. (2020) recommend promoting awareness regarding stress and burnout as a result of increased telecommunication. They note the following measures are likely to combat this type of burnout: increasing the frequency of breaks between virtual lectures and teleconferences to both reduce eye strain and prevent attention loss, increasing podcast-based communication as a substitute for visual screen time, and implementing healthy practices throughout the work or school day. Yoga, in particular, has received growing research attention, with evidence indicating it can be an effective intervention to reduce stress, increase physical activity, and improve well-being.[19-21]

How to Recover from Burnout

Just as the onset and development of burnout change depending on the individual, so too does the recovery. While Heng & Schabram (2021) believe that the best cure for burnout is prevention altogether, that isn’t always realistic. Therefore, they emphasize the importance of agency in the restoration process. Their research finds that to “effectively overcome burnout, employees must feel empowered to take control over their own lives and decisions.” Rather than expect or request a manager to intervene and improve coworker relations, they note that it is more effective for employees to reaffirm their own social networks. In a subsequent study where they surveyed social service workers (people prone to chronic burnout), Heng & Schabram found “those who were already suffering from burnout had a harder time engaging in acts of self- or other-care, [while] those who were able to muster the energy to practice compassion showed significant reductions in burnout.”[22] Other research has found that mindfulness practices such as breathing exercises, gratitude exercises, yoga, and movement can be effective at cultivating compassion, and that compassion meditation training can rewire neural circuitry in the brain.[23,24]

Self-care and healthy practices are crucial to implement for burnout recovery. Such practices can include: 

• reducing screen time

• increasing time in nature

• stretching to mitigate tension brought on by extended sitting

• practicing agency and taking control in areas of work or school where one can make changes for themselves

• reflecting on one’s support system and building relationships where trust and respect are foundational

• engaging in self-compassion

It’s also important to be aware that the symptoms of burnout can resemble those of depression; if one’s cynicism and exhaustion begin to pervade other areas of life besides work, then different approaches (e.g., therapy or medication) may be more effective or necessary for healing to occur. 

For more information, click here to access an interview with SAS Therapist, Jim McDonnell, on high-stress employment.

Contributed by: Maya Hsu

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

References

1 Melamed, S., Shirom, A., Toker, S., Berliner, S., & Shapira, I. (2006). Burnout and risk of cardiovascular disease: Evidence, possible causal paths, and promising research directions. Psychological Bulletin, 132(3), 327–353. https://doi.org/10.1037/0033-2909.132.3.327 

2 Maslach, C., Jackson, S. E., & Leiter, M. P. (1997). Maslach Burnout Inventory: Third edition. In C. P. Zalaquett & R. J. Wood (Eds.), Evaluating stress: A book of resources (pp. 191–218). Scarecrow Education.

3 Koutsimani, P., Montgomery, A., & Georganta, K. (2019). The Relationship Between Burnout, Depression, and Anxiety: A Systematic Review and Meta-Analysis. Frontiers in psychology, 10, 284. https://doi.org/10.3389/fpsyg.2019.00284

4 Storm, K., & Rothmann, S. (2003). The relationship between burnout, personality traits and coping strategies in a corporate pharmaceutical group. South African Journal of Industrial Psychology, 29(4), 35-42. Retrieved from https://www.researchgate.net/publication/47739448_The_relationship_between_b urnout_personality_traits_and_coping_strategies_in_a_corporate_pharmaceutical _group

5 Toker, S., Shirom, A., Shapira, I., Berliner, S., & Melamed, S. (2005). The association between burnout, depression, anxiety, and inflammation biomarkers: C-reactive protein and fibrinogen in men and women. Journal of Occupational Health Psychology, 10(4), 344-362. http://dx.doi.org/10.1037/1076-8998.10.4.344

6 Toppinen-Tanner, S., Ahola, K., Koskinen, A., & Vaananen, A. (2009). Burnout predicts hospitalization for mental and cardiovascular disorders: 10 - year prospective results from industrial sector. Stress and Health, 25(4), 287-296. http://dx.doi.org/10.1002/smi.1282

7 Rosen, I. M., Gimotty, P. A., Shea, J. A., & Bellini, L. M. (2006). Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout 39 among interns. Academic Medicine, 81(1), 82-85. Retrieved from http://journals.lww.com/academicmedicine/Fulltext/2006/01000/Evolution_of_Sl eep_Quantity,_Sleep_Deprivation,.20.aspx

8 Ahola, K., Honkonen, T., Kivimäki, M., Virtanen, M., Isometsä, E., Aromaa, A., & Lönnqvist, J. (2006). Contribution of burnout to the association between job strain and depression: The Health 2000 Study. Journal of Occupational and Environmental Medicine, 48(10), 1023-1030. http://dx.doi.org/10.1097/01.jom.0000237437.84513.92

9 Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World psychiatry : official journal of the World Psychiatric Association (WPA). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4911781/#wps20311-bib-0024 

10 Schaufeli, W., & Enzmann, D. (1998). The burnout companion to study and practice: A critical analysis. Taylor & Francis. 

11 Ghorpade, J., Lackritz, J., & Singh, G. (2007). Burnout and personality. Journal of Career Assessment, 15(2), 240–256. https://doi.org/10.1177/1069072706298156 

12 Anvari, M. R., Kalali, N. S., & Gholipour, A. (2011). How does personality affect on job burnout? International Journal of Trade, Economics and Finance, 2(2), 115-119. Retrieved from http://www.ijtef.org/papers/88-F00068.pdf

13 Dargah, H. G., & Estalkhbijari, Z. P. (2012). The relationship between the Big Five Personality Factors and job burnout. International Journal of Asian Social Science, 2(11), 1842-1850. Retrieved from http://www.aessweb.com/pdffiles/ijass%20pp.1842-1850.pdf

14 American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Pub.

15 Iacovides, A., et al. (2003). The relationship between job stress, burnout and clinical depression. Journal of Affective Disorders, 75(3), 209-221. https://doi.org/10.1016/S0165-0327(02)00101-5

16 Lemola, S., Perkinson-Gloor, N., Brand, S., Dewald-Kaufmann, J. F., & Grob, A. (2014). Adolescents' electronic media use at night, sleep disturbance, and depressive symptoms in the smartphone age - Journal of Youth and adolescence. SpringerLink. Retrieved January from https://link.springer.com/article/10.1007/s10964-014-0176-x?r=1&l=ri&fst=0&error=cookies_not_supported&code=20def7ff-647e-4b3f-923a-66c0a437f01b 

17 Hossmann, K.-A., & Hermann, D. M. (2002). Effects of electromagnetic radiation of mobile phones on the Central Nervous System. Bioelectromagnetics, 24(1), 49–62. https://doi.org/10.1002/bem.10068 

18 Mheidly, N., Fares, M. Y., & Fares, J. (2020). Coping with stress and burnout associated with telecommunication and online learning. Frontiers in public health. Retrieved from https://www.frontiersin.org/articles/10.3389/fpubh.2020.574969/full 

19 Pascoe, M. C., & Bauer, I. E. (2015). A systematic review of randomised control trials on the effects of yoga on stress measures and mood. Journal of Psychiatric Research, 68, 270–282. https://doi.org/10.1016/j.jpsychires.2015.07.013 

20 Büssing, A., Michalsen, A., Khalsa, S. B., Telles, S., & Sherman, K. J. (2012). Effects of yoga on mental and physical health: A short summary of reviews. Evidence-Based Complementary and Alternative Medicine, 2012, 1–7. https://doi.org/10.1155/2012/165410 

21 Fares, J., & Fares, Y. (2016). The role of yoga in relieving medical student anxiety and stress. North American Journal of Medical Sciences, 8(4), 202. https://doi.org/10.4103/1947-2714.179963 

22 Heng, Y. T., & Schabram, K. (2021). Your Burnout is unique. your recovery will be, too. Harvard Business Review. Retrieved from https://hbr.org/2021/04/your-burnout-is-unique-your-recovery-will-be-too 

23 Kirby, J. N. (2016). Compassion interventions: The programmes, the evidence, and implications for research and Practice. British Psychological Society. Retrieved from https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1111/papt.12104 

24 Weng, H., Fox, A., Shackman, A., Stodola, D., Caldwell, J., Olson, M., Rogers, G., & Davidson, R. (2013). Compassion training alters altruism and neural responses to suffering - journals.sagepub.com. Psychological Science. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/0956797612469537?cited-by=yesl0956797612469537v1p0956797612469537v1r0956797612469537v1 

Therapeutic Benefits of Play Therapy

Source: Canva

What is Play Therapy and How Does It Work? 

Play therapy is a type of therapy, primarily used with children, to enter their world and understand what kinds of things they are processing at any given moment. It can look like placing a child in a circle of toys, role playing imaginary characters, or using a sandtray to depict scenes. The key is to let the child lead and not to interfere with the direction in which they want to go. 

Sandplay therapy (SPT) is one common medium used in play therapists’ offices. Foo & Pratiwi (2021) have measured a significant decrease in anxiety related symptoms when SPT is optimized. Choline, an advantageous metabolite marker linked to learning, memory, and concentration, was found to increase in participants with childhood trauma after receiving SPT treatment.[1] For children who experience trauma such as divorce, hospitalization, or loss of a loved one, play therapy can mitigate the accompanying negative effects and act as a buffer to prevent severe psychosocial or emotional issues from developing.[2]

Why Play Therapy?

Children will often repeat certain narratives over and over again until they’ve processed them through play. For example, if a child’s best friend suddenly stops playing with them at school, the child may need to work through that confusion through reenactment. When something in the world is frightening or traumatizing in any way, the child can make better sense of the situation by acting it out and having the ability to anticipate what will happen next. They can set the pace of the reenactment as well as gain distance from the situation because rather than the child re-experiencing the fear, the toy or doll can now stand in for them. 

Research has shown that play therapy is an effective intervention for decreasing anxiety in elementary school aged children, improving disorders like generalized anxiety disorder, agoraphobia, social anxiety, and separation anxiety.[3-5] With adults, the brain is typically more developed, so talking is usually an effective method for processing issues. Despite the fact that talking is a viable and reliable option for adults working through problems, the incorporation of playful elements can still be tremendously beneficial for the average person. Similar to how bringing pinecones into a session (as a form of ecotherapy) can spark memories, ideas, and conversations about nature that might not otherwise have organically arisen, using painting or crafts can elicit unique feelings or thoughts in a client. Adults with developmental disabilities can also benefit immensely from toy-based play therapy, as the objects or role play can function as a bridge into their world. 

Drama, somatic, and art therapy are closely related to play therapy in that they all involve additional engagement from the body and mind than just speech. Drama therapy has been shown to improve self-awareness and help people materialize their hidden feelings through action.[6] Additionally, research has demonstrated how somatic experiencing can be therapeutic for people with PTSD, and how creative art-based expression has positive effects on physiological and psychological health.[7, 8] Play therapy is unique in its broadness, as it can encompass the other three as well. Due to its range, it is usually possible to find some form of play therapy that works for each child. Younger children may prefer to act as a dinosaur, while older kids may prefer to use a toy dinosaur in a sandtray. As the brain develops through childhood, analytical skills are built through the limbic brain, and a kid becomes better able to-- for example-- construct more complex sandtray arrangements and then discuss their choices.[9] 

Symbolism in Play Therapy

In the world of play therapy, symbolism is a key element for understanding the broader context of a child’s play. However, a delicate line must be walked: no selection of an object nor appearance of a recurring narrative is ever completely random or arbitrary (in other words, everything is clinically relevant), yet the therapist must be careful not to draw assumption-based conclusions about the symbolism. For example, a child may select a toy weapon. This does not necessarily indicate pathology or a history of abuse. Instead, it might represent desire on the child’s part for some power and control-- something children typically lack in the world. 

Figure 1: Themes of toy selection

Note: This table was produced by Andrewjeski (2019) [10]

Play Therapy Extends Beyond the Session

Parents sometimes place their children in play therapy to give them “me” time. Rachael Sofian, a psychotherapist at Seattle Anxiety Specialists trained in play therapy, notes that children rarely truly crave autonomy. Instead, they seek connection. When done mindfully, it can be effective for parents to engage in play therapy at home. In fact, the greatest results from having a child in play therapy come from the integration of certain attunement techniques into home life. “Reflecting” is a term for the non-directive play therapy technique where the adult or therapist verbalizes the choices of the child. “You’re brushing that doll’s hair” and “you’re moving the car really fast” are examples of reflecting that can help foster connection between the child and adult.[11] 

However, Sofian recommends consulting a professional play therapist for tailored advice before implementing techniques at home. By starting a child in play therapy, the therapist can get to know them and discover important patterns, and then communicate activities or exercises for the parent to try out with the child later. Without professional involvement a parent may run the risk of causing harm to the child, for instance, by setting aside play time but multi-tasking or forgetting to be fully present.

There is considerable evidence that supports the efficacy of play therapy for improving social and emotional skills, self-awareness, self-regulation, empathy, communication, increasing intelligence, decreasing anxiety, and helping with the recovery process after trauma.[12-14] By placing power into the child’s hands and allowing them to direct a play session, they gain an invaluable sense of control and autonomy. Trained professionals who can reflect, validate, and ask questions in a neutral and curious manner add to the power of play therapy. The therapeutic benefits are not limited to children or the brick-and-mortar therapy room, though. Elements of therapeutic play can be implemented into virtual therapy, home life between the parent and child, as well as psychotherapy sessions for adults.  

Contributed by: Maya Hsu

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

References

1 Foo, M., & Pratiwi, A. (2021). The effectiveness of sandplay therapy in treating generalized anxiety disorder patients with childhood trauma using magnetic resonance spectroscopy to examine choline level in the dorsolateral prefrontal cortex and centrum semiovale. International Journal of Play Therapy, 30(3), 177–186. https://doi.org/10.1037/pla0000162 

2 Li, W. H. C., Chung, J. O. K., Ho, K. Y., & Kwok, B. M. C. (2016). Play interventions to reduce anxiety and negative emotions in hospitalized children. BMC pediatrics. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4787017/ 

3 Hateli, B. (2021). The effect of non-directive play therapy on reduction of anxiety disorders in young children. Counselling and Psychotherapy research. Retrieved from https://www.researchgate.net/publication/352540147_The_effect_of_non -directive_play_therapy_on_reduction_of_anxiety_disorders_in_young_children

4 Kool, R., & Lawver, T. (2010). Play therapy: Considerations and applications for the practitioner. Psychiatry (Edgmont (Pa. : Township)). Retrieved January 13, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989834/ 

5 Ray, D. C., Armstrong, S. A., Balkin, R. S., & Jayne, K. M. (2014). Child-centered play therapy in the schools: Review and meta-analysis. Psychology in the Schools, 52(2), 107–123. https://doi.org/10.1002/pits.21798 

6 Chang, W.-L., Liu, Y.-S., & Yang, C.-F. (2019). Drama therapy counseling as mental health care of college students. International journal of environmental research and public health. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6801780/ 

7 Brom, D., Stokar, Y., Lawi, C., Nuriel-Porat, V., Ziv, Y., Lerner, K., & Ross, G. (2017). Somatic experiencing for posttraumatic stress disorder: A randomized controlled outcome study. Journal of traumatic stress. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518443/ 

8 Stuckey, H. L., & Nobel, J. (2010). The connection between art, healing, and public health: A review of current literature. American journal of public health. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804629/ 

9 Sokolowski, K., & Corbin, J. G. (2012). Wired for behaviors: From development to function of innate limbic system circuitry. Frontiers in molecular neuroscience. Retrieved January from https://www.frontiersin.org/articles/10.3389/fnmol.2012.00055/full 

10 Andrewjeski, K. (2019). The symbolism of play behavior in child-centered play therapy. UNLV Theses, Dissertations, Professional Papers, and Capstones. Retrieved from http://dx.doi.org/10.34917/18608580 

11 Allen, V., Folger, W., & Pehrsson, D.-E. (2007). Reflective process in play therapy: A practical model for supervising counseling students. Researchgate. Retrieved from https://www.researchgate.net/publication/234565195_Reflective_Process_in_Play_Therapy_A_Practical_Model_for_Supervising_Counseling_Students 

12 Mirahmadi, Z., & Hemmati, G. (2016). The effectiveness of group play therapy on social skills of female students with intellectual disability. Physical Treatments - Specific Physical Therapy, 6(2), 115–123. https://doi.org/10.18869/nrip.ptj.6.2.115 

13 Chinekesh, A., Kamalian, M., Eltemasi, M., Chinekesh, S., & Alavi, M. (2013). The effect of group play therapy on social-emotional skills in pre-school children. Global journal of health science. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4825459/ 

14 Godino-Iáñez, M. J., Martos-Cabrera, M. B., Suleiman-Martos, N., Gómez-Urquiza, J. L., Vargas-Román, K., Membrive-Jiménez, M. J., & Albendín-García, L. (2020). Play therapy as an intervention in hospitalized children: A systematic review. Healthcare. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551498/ 

The Great Resignation: Why Burnout Prevailed and What to Consider if You’re Contemplating Resigning

Source: Canva

The Great Resignation

Will it Continue through 2022?

2022 is upon us. With the New Year, many tend to commit to grand new routines (going to the gym, eating better, learning a new skill, etc.) and during this ongoing pandemic, one must wonder if positive changes in terms of employment, education and/or new perspectives are also on the calendar. Contemplating a career change? Read ahead for some points to consider, and hear SAS therapists’ perspectives, as you weigh your options.

Along with the COVID-19 pandemic, came what has been dubbed “The Great Resignation” in which millions of Americans have quit their jobs. But, why? In March 2020, countless offices and business were forced to abruptly shutter; millions lost their jobs and an estimated 42% of Americans began to work remotely.[1] This restructuring to work remotely has had a profound impact on how people think about their jobs, specifically when and where they want to work. In a June 2021 article, NPR quotes Tsedal Neeley, a professor at Harvard Business School and author of the book Remote Work Revolution: Succeeding from Anywhere, “We have changed. Work has changed. The way we think about time and space has changed." Neeley then adds a key point - “Workers now crave the flexibility given to them in the pandemic - which had previously been unattainable.”[2]

The crisis of the pandemic, fear of becoming ill and/or losing a loved one as well as fear of the unknown led to Americans beginning to see their life-work balance through a new lens. Many began to rethink what their work means to them, how they are valued in the workplace and how they spend their time. This has led to a significant increase in resignations, with the U.S. Labor Department reporting over four million people quitting their jobs from July-November of 2021 as Covid infections continued to spread throughout the United States. While normally high quit-levels are indicative of a healthy economy with plentiful jobs, the pandemic has led to the worst U.S. recession in history, with millions of people out of work. At the same time, acute labor shortages are being reported.[3]

It’s important to note that while the primary focus of this article is about the “Great Resignation” wherein people have chosen to leave their place of employment, roughly 10 million Americans have unwillingly lost their jobs during the pandemic.[4] Restaurants have shuttered, concert venues fell silent, small businesses collapsed and countless Americans found themselves in severe financial insecurity. Notably, women have borne the brunt of job losses as they are over-represented in low-wage service jobs, have been hit hard by increased child-care demands brought on Covid’s disruption of school reopenings as well as the initial lack of vaccines for children.[5] Further, those with compromised immune systems and/or underlying medical conditions (or who have family/loved ones with such) have had to be especially vigilant to not become exposed to the Coronavirus; thus many have been unable to return to their jobs if exposure was probable, due to safety concerns. In a January, 2022 article by The Guardian, Heidi Shierholz, president of the Economic Policy Institute noted, “We know there are millions of people who are still out of the labor force because of health and safety concerns. We know that parents are out of the labor force because of ongoing Covid-related care responsibilities.”[6] For those unwillingly out of the workforce during this health crisis, the following information and considerations should also be of benefit when contemplating next career steps.

SECTORS FACING GREATEST WALK-OFFS

As The Washington Post reports, those resigning seem to come from every industry and span generations. Those in the leisure and hospitality services have been primary contributors of the mass exodus in the Great Resignation. According to NRP, these industries (which includes jobs in hotels, bars, restaurants, theme parks and entertainment venues) have become increasingly stressful during the pandemic, with scant staffing and constant battles with unmasked customers building up to many departing their jobs. In addition, because those working in the leisure/hospitality sectors have had maintained contact with the public, workers in these fields have been subjected to increased exposure to Covid as they could not isolate nor work remotely in these positions. As many companies leisure/hospitality companies offered furloughs, workers accepted at an unprecedented rate due to the increased stressors and risk of infection.[7]

But it’s not just the leisure/hospitality sectors that are seeing massive quit levels. Data from the Bureau of Labor Statistics has shown an exodus of workers leaving retail, warehouses, food service, health-care and social- assistance jobs at record levels. Quit levels have soared among manufacturing and warehouse workers, straining under excessive pressures of surging demand and crunched supply chains. The Post cites reasons for leaving one’s position during the pandemic include: following through on long-deferred plans to leave; no longer willing or able to wait out the pandemic; being burned out from too many long shifts; too many late nights and unspent vacation days. Furthermore, the public health crisis led to a reassessment of one’s jobs and priorities.[8]

Economists have noted that the pandemic has led to low-wage workers in America revolting against years of poor pay and stressful conditions. Many are now less-willing to endure inconvenient hours with low compensation, leading to the pursuit of better opportunities.[9]

Ian Cook and his team at Harvard Business Review sought to explore the staggering statistics of quits occurring since the pandemic occurred. They conducted an in-depth analysis of more than 9 million employee records from more than 4,000 companies.[10] The global dataset included employees across a variety of industries, functions, and levels of experience, and revealed two key trends.

1. Resignation rates are highest among mid-career employees, aged 30-45. Employees in this age group (dubbed “mid-career” by the researchers) have had the greatest increase in resignation rates, with an average increase of more than 20% between 2020 and 2021. Cook and his team note that there are a few factors to help to explain why the increase in resignations have been largely driven by this cohort. Namely, mid-level employees are more-likely to be fully trained in their positions, making remote work a relatively easy shift compared to someone with less experience in the company. The team notes this could create greater demand for mid-career employees, giving them greater leverage in securing new positions.

Additionally, it is possible that many mid-level employees may have delayed transitioning out of their roles due to the uncertainty caused by the pandemic. Cook suggests the spike in resignations could be the result of more than a year’s worth of pent-up work frustrations and pressures such as continual high workloads, hiring freezes, and other pressures, causing workers to rethink their work and life goals.[11]

2. Resignations have been highest in the tech and health care industries. Cook et al. also identified notable differences in turnover rates between companies across different industries and found the health care industry had a 3.6% increase, while the tech sector had a 4.5% increase in resignations from 2020-2021.

The team suggested that resignation rates were higher among employees who worked in fields that had experienced extreme increases in demand due to the pandemic, likely leading to increased workloads and burnout. [12]

A NEW PERSPECTIVE

An unforeseen side-effect of the pandemic has been that much of the workforce has come to rethink their current careers, priorities and lifestyles. According to Gallup research conducted in the summer of 2021, nearly half of American workers were actively searching or watching for new job opportunities.[13] And, at the end of November 2021, there were more than 10.6 million unfilled jobs in the U.S. workforce, according to data released by the Labor Department,[14] thus suggesting that workers are taking time to find the “right” positions for themselves. Further, with government stimulus leading to surges in savings, booming stock markets and fewer spending options during the pandemic, some households have more funds to sustain them in the interim as workers seek to find more ideal employment situations.[15] Additionally, as The Guardian notes, “For those quitting in response to higher wages or greater health risks or greater care insecurity, it is not so simple as to think that they would prefer not to work, but rather, that they cannot afford to keep the jobs they have.”[15]

Grant Thornton’s recent “State of Work in America” survey found that flexibility is key for many employees now, in regards to when and where work is done. Respondents indicated that flexibility actually outweighs compensation as a concern and half of the sample noted they would give up a salary increase for more flexibility. Given that burnout is a top reason why employees seek out other opportunities, flexibility can be the primary mitigating factor.[16] Out of Office co-author, Anne Helen Petersen, asserts "The status quo of us being in offices from a certain time to a certain time every day is very arbitrary. It's based on rhythms that are no longer ours. It's based on an understanding that there is a caretaker at home for most families in the United States, and that's not necessarily the case." Now is a good time to revisit what she calls "arbitrary understandings of how many hours your butt should be in a chair in the office." After all, notes Petersen, "You don't need to be in an office to answer emails."[17]

The result of such high unemployment numbers have led to a shift in the worker having increased bargaining and negotiation powers. Mark Hamrick, senior economic analyst at Bankrate asserts, “As a result of many changes caused by the pandemic, many employers will need to continue to consider raising wages and improving working conditions, such as providing more flexibility, as they attempt to attract and retain workers.”[18]

The proverbial battle for talent in the workplace has spurred some companies to raise wages and offer sign-on bonuses. In May, the national average hourly pay for non-managers at restaurants and bars topped $15. Companies such as Costco, Amazon, CVS and Walgreens all have hourly minimums of $15 or higher. Further, Walmart, Target and Amazon announced they would begin offering free college tuition and textbooks to employees.[19]

IMPROVING WORKER RETENTION

Explorance, a leader in experience management (XM) solutions, commissioned a survey of 2,000 U.S. part- and full-time-employed adults to probe hidden drivers behind The Great Resignation. Their key finding came down to: “feedback that goes unheard.”[20]

A majority of respondents noted they are eager to share feedback with employers and do so in the hopes of driving positive change in their workplace. However, employees (including many executives) indicated that far too often their feedback goes unheard and does not result in meaningful change. Moreover, while 78% of respondents indicated they were “eager to take company surveys,” 50% noted they were not surveyed by their employer in the previous year. Further, 45% of the sample felt that even when surveys were implemented, no meaningful change ever comes from them.[21]

Samer Saab, founder and CEO of Explorance, notes, "This data not only reveals new insights as to why employees are looking to change jobs. It also shows that responding to employee feedback by making meaningful changes can improve employee inclusion and retention."[22]

Explorance suggests that employers can take three steps to slow attrition:[23]

1. Solicit feedback from employees, including open-ended questions that allow them to speak candidly and share their thoughts.

2. Analyze the survey results and communicate the key findings to employees.

3. Act. To truly close the loop, employers must quickly turn insights into action and address employee concerns rapidly -- or risk hearing about them again in exit interviews.

Flexibility in the workplace is another factor that can slow the number of resignations a company experiences. While some personality types thrive in an office environment, others shine away from the fray and perform better remotely. Shifting hours or split schedules for remote work are another driver of employee satisfaction; if the company’s business hours align, employees can work 7:00-3:00, or even a split day of 9:00-3:00 plus 7:00-9:00 which may accommodate people with school-aged children better or those who have higher productivity with a break mid-day. Additionally, some workers need a break from home and do best with the separation of work and home spaces; thus, allowing a flex-schedule for employees to work from the office some days and home other days, may be of benefit.[24]

CONSIDERING YOUR OPTIONS

Telford and Gregg of The Washington Post offer that if someone is contemplating resigning from their job but are unsure if or when they should, they may want to consider some options:

- Can you move to a different team or department to increase satisfaction?

- Can you take on fewer tasks, add more-interesting tasks, or shift some responsibilities?

- Is there something your employer could provide (e.g., more money, a promotion, more time off) that would give your role more meaning?

Given the current labor climate, employees have stronger negotiating power when requesting change. If managers don’t engage in discussions and/or requests for change, then that might be the answer one needs.[25]

Q&A

SAS THERAPISTS OFFER INSIGHTS FOR THOSE CONSIDERING RESIGNATION

1) From a therapist’s perspective, how can someone know if they are at a point that they should resign from their current employment?

“I’m not sure I can give a definitive answer here, as context is very important. Generally speaking, if someone is spending a large amount of time thinking about quitting their job, then it is worth spending some time exploring this as an option in more detail, with the goal of moving from a reactive to a more intentional relationship to these ruminations.

The first thing I would suggest is that they get clarity on why they are considering leaving their job. They might be able to do this on their own through introspection, journaling, and/or meditation. That said, it can be much more helpful and effective to talk to someone about this - a career counselor, a psychotherapist, or someone else you trust who can be objective in helping you gain clarity on your motivations for leaving.

Some questions to consider: Do I want to quit my job, or do I want to quit my profession? Is it because I don’t like what I do for work? Do I not like who I am working for? Is it because I am anxious and/or depressed to the point that it is negatively impacting my life? Do these symptoms transcend my current work, or is it something I only experience with this particular job? Are there skills and treatments I can use to manage these symptoms?

Again, all of these questions should help an individual get clarity on why they want to quit their job.” (Jim McDonnell, LMHC)

“When someone cannot reach a proactive, solutions-focused way forward that accounts for the needs of both the employee and the employer - (the employee having had their needs and feelings understood and validated by a trusted other) - then it's time to resign (generally speaking, my opinion only).”  (Liz Silvestrini, JD, LMHC)

2) For those resigning or considering resigning from their current employment, what guidance/advice would you offer them?

“If you have done the work on gaining clarity on why you want to leave, and have determined it does in fact make sense to quit (the Why), then it makes sense to consider the How and When of your departure.

Some questions to consider: Do you have resources and a plan for what happens up to and after your departure? Are their benefits or resources you can use to help ease the transition? Do you have social support to lean on during this time?

The theme here is, again, gaining clarity and intention rather than being impulsive and reactive.” (Jim McDonnell, LMHC)

 “Focus on what you want for your next chapter and maintain that focus throughout the process to keep yourself in a position of empowered, forward momentum.” (Liz Silvestrini, JD, LMHC)

3) Do you have any other guidance/advice for someone dealing with a particularly stressful/potentially toxic work environment?

“The most important guidance I can give is to talk about this in a constructive way with someone. Someone who can help you gain clarity on your situation, provide care and support, and help you come up with options and a plan so that you feel empowered and intentional in the face of uncertainty and distress.” (Jim McDonnell, LMHC)

“Remember that you always have choices (forgive me or slap me if this sounds privileged, because it is). Remember that you have inherent dignity and worth and never deserve to live in toxicity. If something isn't serving you, find something else and write about your experience because this is never easy and your story will matter to the next person.” (Liz Silvestrini, JD, LMHC)

For more information, click here to access an interview with SAS Therapist, Jim McDonnell, on high-stress employment.

Additionally, you may click here to access an interview with Psychiatrist David Neubauer on insomnia & anxiety.

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

Jim McDonnell, LMHC & Liz Silvestrini, JD, LMHC

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

References

1 “Working 9 to 5? 'Out of Office' Author Says Maybe it's Time to Rethink That,” NPR: Author Interviews. (accessed 1-3-2022). https://www.npr.org/2021/12/13/1062991645/out-of-office-author-ann-helen-petersen

2 “As The Pandemic Recedes, Millions of Workers Are Saying 'I Quit',” NPR. (accessed 1-4-2022). https://www.npr.org/2021/06/24/1007914455/as-the-pandemic-recedes-millions-of-workers-are-saying-i-quit   

3 Ibid.

4 “Fewer Jobs Have Been Lost in the EU Than in the U.S. During the COVID-19 Downturn,” Pew Research Center. (accessed 1-3-2022). https://www.pewresearch.org/fact-tank/2021/04/15/fewer-jobs-have-been-lost-in-the-eu-than-in-the-u-s-during-the-covid-19-downturn/

5 “Why is Everyone Quitting, and How Do I Know Whether it’s Time to Leave My Job?,” The Washington Post. (accessed 1-4-2022). https://www.washingtonpost.com/business/2021/10/13/great-resignation-faq-quit-your-job/

6 “Quitting is Just Half the Story: The Truth Behind the ‘Great Resignation,’” The Guardian. (accessed 1-5-2022). https://amp.theguardian.com/business/2022/jan/04/great-resignation-quitting-us-unemployment-economy

7 NPR.

8 The Washington Post.

9 Ibid.

10 “Who Is Driving the Great Resignation?,” Harvard Business Review. (accessed 1-4-2022). https://hbr.org/2021/09/who-is-driving-the-great-resignation

11 Ibid.

12 Ibid.

13 “The 'Great Resignation' Is Really the 'Great Discontent',” Gallup. (accessed 1-5-2022). https://www.gallup.com/workplace/351545/great-resignation-really-great-discontent.aspx 

14 “Job Openings and Labor Turnover Summary,” U.S. Bureau of Labor Statistics: Economic News Release. (accessed 1-5-2022). https://www.bls.gov/news.release/jolts.nr0.htm 

15 The Washington Post.

16 The Guardian.

17 Ibid.

18 NPR: Author Interviews.

19 The Washington Post.

20 Ibid.

21 “Why Are People Really Leaving Their Jobs? The Whole Reason Can Be Summed Up in 4 Words,” Inc. (accessed 1-3-2022). https://www.inc.com/marcel-schwantes/why-are-people-really-leaving-their-jobs-whole-reason-can-be-summed-up-in-4-words.html      

22 Ibid.

23 Ibid.

24 Ibid.

25 NPR: Author Interviews.

26 The Washington Post.

Demystifying Group Therapy

Image Source: Shutterstock

What is Group Therapy?

The origins of the group therapy we know today began in the early twentieth century when it was used to support Tuberculosis patients in the hospital setting and later to support WWII soldiers (Barlow et al., 2004). Since then group therapy has undergone many changes, theoretical modalities have been created, and researchers have studied its effectiveness. Group therapy relies on the restorative power of relationships developed in a dedicated and supportive community. Joining a group provides a dedicated space for growth alongside a group of individuals who are committed to uplifting one another through the process.

What happens in a group session?

Groups can be focused on a theme, diagnosis, or lived experience (to name a few), and group members will gravitate towards themes that resonate with their goals and needs. For some, this may be the first time they have been in a community space with people who can uniquely understand part of their lived experience.

Group therapy allows for connection over common ground, whether that is the commitment to personal growth or a history of a particular diagnosis. The diversity of the group provides a wealth of unique perspectives.

Group therapy leverages the interpersonal dynamics present in the session as a vehicle for growth, and these dynamics can also shed light on specific behaviors that may not play out in individual therapy. As these dynamics unfold, they can be re-written in the here-and-now with the support of other members and the facilitator(s).

Please know that this is a high-level view of groups, and each group's content and flow will depend on the facilitators' style and modality. However, most sessions will begin and end with a check-in/out, and the rest of the session will focus on the primary theme, skill, activity, and/or a certain amount of processing.

The facilitator, a therapist, plays a pivotal role in the progression of the therapeutic aspects of group therapy. As noted above, the group leverages interpersonal dynamics and community as vehicles for growth. This process is supported by the therapist, who creates a space for these forces to unfold. Additionally, the facilitator provides feedback, supports insight development amongst members, and aids in conflict resolution as it arises.

The Seattle Psychiatrist Interview Series will be interviewing thought leaders in the group therapy space over the next few months, so please check back to hear from group therapists bringing creativity, research, and evidence-based practice to the therapeutic space.

Image Source: Shutterstock

Is Group Therapy for Me?

Individual therapy and group therapy have their unique place in helping you achieve your personal growth goals. One of the core elements of group therapy is the community element and the focus on group dynamics as a medium for growth. Group therapy may happen in parallel to individual treatment.

Depending on group content, facilitators may have certain exclusionary criteria or requirements (e.g., suicidal ideation). Contact the facilitator if you are unsure if you qualify for a group or if the group context will appropriately meet your needs.

Reflection questions as you consider group therapy:

1. What goals do I have for group therapy?

2. What is prompting me to explore this now?

3. What is my previous experience with group experiences (activities, therapy, etc.), and how may that have an impact on how I show up in the group?

4. What concerns about the process do I have that may have an impact on how fully I show up and the extent to which I commit to the experience?

5. In what environment do I learn best?

Getting the most out of a group requires a commitment to the process, a willingness to be open and present, and an interest in learning from others.

Group effectiveness 

Group therapy is equally effective as individual therapy in treating a wide variety of clinical concerns. In fact, in a research study comparing the two modalities, the authors concluded that there was a "significant reduction in both depression and anxiety scores... with no significant difference between group and individual therapy outcomes" (Fawcet et. al, 2019, p. 430).

Furthermore, they challenged the notion that individual therapy is the primary medium through which intense change can occur and stated, "group therapy need not be viewed as a 'step down' from individual therapy, but that it can be just as intensive of an intervention as individual therapy" (Fawcet et. al, 2019, p. 436).

Irvin Yalom, one of the primary thought leaders and researchers in group therapy, studied the factors which contribute to group effectiveness and identified a “construct of the curative process in group psychotherapy” (Butler & Fuhriman, 1983, p.131). Through decades of research on group therapy, "the triad of self-understanding, catharsis, and interpersonal learning (input) [are shown] as the most highly valued factors in outpatient therapy groups" (Butler & Fuhriman, 1983, p.140).

Image Source: The Theory and Practice of Group Psychotherapy, Yalom (1995): PositivePsychology.com

6 tips to get the most out of group:

1. Intention: Set a clear intention for your group experience

2. Fit: Identify a group that fits your needs (seek out an individual therapist and discuss with the group leader for additional support)

3. Relationships: Invest in the interpersonal relationship and respect each person's unique perspective and process

4. Growth: Utilize a growth mindset by conceptualizing tension as an opportunity for progress 

5. Commitment: Commit to the experience and embrace the process

6. Openness: lead with curiosity and presence 

Additional Resources

Here are a few resources to explore as you continue to learn more about group therapy and identify the best fit:

• Group: How One Therapist and a Circle of Strangers Saved My Life (A New York Times Bestseller by Christie Tate, 2021)

• Check out these two lighthearted videos that provide additional insight into the group process: "What is Group Therapy? An Animated Short" and this clip from The Looney Tunes Show

If you’re ever interested in joining a group, you can always reach out to the facilitator and inquire if you have specific questions about the content and/or structure of their group - or to ask if they have any further resources you can use in your journey.

If you would like to learn more about participating in an upcoming group at Seattle Anxiety Specialists, PLLC, please reach out to info@seattleanxiety.com or check here for more information.

Contributed by: Sonya Jendoubi, MS., LMHC

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

References

1 Barlow, S. H., Fuhriman, A. J., & Burlingame, G. M. (2004). The History of Group Counseling and Psychotherapy. In J. L. DeLucia-Waack, D. A. Gerrity, C. R. Kalodner, & M. T. Riva (Eds.), Handbook of group counseling and psychotherapy (pp. 3–22). Sage Publications Ltd.

2 Fawcett, E., Neary, M., Ginsburg, R., & Cornish, P. (2019). Comparing the effectiveness of individual and group therapy for students with symptoms of anxiety and depression: A randomized pilot study. Journal of American College Health, 68(4), 430–437. https://doi.org/10.1080/07448481.2019.1577862

3 Butler, T., & Fuhriman, A. (1983). Curative factors in group therapy. Small Group Behavior, 14(2), 131–142. https://doi.org/10.1177/104649648301400201

The Need for Ecotherapy in Our Overstimulated, Over-Industrialized World

The Science Behind Ecotherapy

From the smells of essential oils emitted by trees to the sounds of running water, there are significant findings that support the calming, healing, and restorative aspects of spending time in nature. In The Nature Fix (2017), Florence Williams investigates and explains a multitude of ways nature benefits humans both psychologically and physiologically. Since our world has begun rapidly urbanizing, people have lost touch with the surroundings in which we adapted, evolved, and thrived. According to Williams, we don’t experience nature often enough anymore to realize how restored it can make us feel, “nor are we aware that studies also show [natural environments] make us healthier, more creative, more empathetic and more apt to engage with the world and with each other.” To support her claim that despite our rapid industrialization, nature remains an innate value of humans, Williams notes that humans “pay considerably more for residences or hotel rooms right on the beach, or the pastoral ninth hole, or a quiet, tree-lined street.” Additionally, experts find that “these habitat preferences are remarkably consistent across cultures and eras.” As a result of our increased separation from the natural environment we still instinctively crave, levels of stress, depression, diabetes, migraines, hypertension, and crime are elevated while attention, memory, eyesight, and social skills worsen.[1] 

Much of what scientists have begun to confirm about the health benefits of nature have long been known and treasured by Indigenous peoples. When discussing the role nature plays in mental well-being, it would be remiss to ignore the fact that the intertwinement of humans and the natural world is Indigenous wisdom that has been around for centuries. Charles and Cajete (2020) write, “Evidence is growing within non-Indigenous communities of the scientific validity of these ancient as well as contemporary practices, and their adaptive value today and for the future.” Instead of the scientific method, traditional and Indigenous wisdom is “based on natural law, the workings of the land and relationships… the essence of Native science is predicated on seeking and supporting life.”[2] Because most Indigenous languages do not have a word for “science,” Indigenous philosopher Kyle Whyte uses the term traditional ecological knowledge (TEK) instead. Whyte defines TEK as “the knowledge, practice, and belief concerning the relationships of living beings to one another and to the physical environment, which is held by peoples in relatively nontechnical societies.” TEK and science differ in their rationality, but are complementary disciplines; TEK is beneficial to scientific advancement. One reason that’s been noted as to why Indigenous communities do not conduct research is because, “Societies without computing capacities built into their TEK systems cannot value quantitative research in the same way that it is valued in natural science disciplines.”[3] Thus, the rise of ecotherapy and nature-based interventions may be new to the Western world, but is in no way a modern discovery nor novel idea to be claimed. 

To understand why nature offers such beneficial rewards to the human body, one can look to the biophilia hypothesis for a fundamental explanation. Williams (2017) explains this hypothesis succinctly: “We feel most ‘at home’ in nature because we evolved there.” Given that humans have a predisposed inclination toward nature, we can build upon the biophilia hypothesis with two pronounced theories that support this claim: the Stress Recovery Theory (SRT) and Attention Restoration Theory (ART). These two theories have surfaced through research on restorative environments, and speak to different aspects of the recovery powers of nature. Rita Berto, an environmental psychologist, finds that “although in both theories natural environments are more restorative than urban or artificial environments, they differ in what drives individuals toward a restorative place: In SRT it is physiological stress, whereas in ART it is mental fatigue.”[4] In Figure 1, the component of nature is visualized as an important step on the way toward restoration, and even more crucial for vitalization. ART and SRT are two theories that, in conjunction with the biophilia hypothesis, provide scientific rationale for the efficacy and legitimacy of eco-psychological interventions.

Figure 1

Process of personal and environmental aspects of fatigue and recovery

Note: This sketch was produced by Rydstedt & Johnsen in 2019 [5]

One reason nature-based therapies and environmental calls-to-action are gaining popularity is due to the rise in ADHD diagnoses in children.[6] Williams finds that, “Of the 6.4 million diagnosed kids in America, half are taking prescription stimulants, an increase of 28 percent since 2007” (Williams p. 233). The Attention Restoration Theory (ART) presents reasoning for why nature is advantageous specifically for focus and concentration. Originally proposed by Stephen and Rachel Kaplan, ART works through four different cognitives states: 1) a clearing of the head, 2) mental fatigue recovery, 3) soft fascination, and 4) reflection.[7] Therefore, as someone takes a walk, their attention becomes increasingly restored because of the lack of cognitive demand, as well as the added scenery and stimuli that evoke reflection and interest in the person. One notable study conducted by Frances Kuo and Andrea Taylor (2004) found that kids showed fewer ADHD symptoms after spending time in nature. The symptoms evaluated in their study included: remaining focused on unappealing tasks, finishing tasks, listening to and adhering to directions, and restraining oneself from distractions. Kuo and Taylor suggest that “green time” can be used to supplement or even replace ADHD medication, especially in cases where medication is undesirable or ineffective.[8] 

Richard Louv coined the term “nature-deficit disorder” in his 2005 book, Last Child in the Woods. In the book’s introduction, Louv writes that rapidly advancing technologies “are blurring the lines between humans, other animals, and machines. The postmodern notion that reality is only a construct-- that we are what we program-- suggests limitless human possibilities.” In trying to build technologies that will allow us to manipulate and control every aspect of our reality, Louv argues that “the young spend less and less of their lives in natural surroundings [and] their senses narrow, physiologically and psychologically, and this reduces the richness of human experience.”[9] Ecotherapy is one way to reconnect with the natural roots from which humankind came. A burgeoning kind of therapy, ecotherapy has promising research and comparable effectiveness to other types of therapy and medication. Buzzell and Chalquist (2005) explain ecotherapy as an “umbrella term for nature-based methods of physical and psychological healing,” which “represents a new form of psychotherapy that acknowledges the vital role of nature and addresses the human-nature relationship.” In their book Ecotherapy: Healing with Nature in Mind, Buzzell and Chalquist put to rest some of the diminutive myths that surround ecotherapy (e.g., it’s a fad, or it just involves thinking good thoughts), and emphasize the dire need for increased nature integration in today’s world: 

The problem of our day is an inner deadening, an increasingly deployed defense against the stresses of living in an overbuilt industrialized civilization saturated by intrusive advertising and media, unregulated toxic chemicals, unhealthy food, parasitic business practices, time-stressed living, and (in the United States) relentlessly mindless political propaganda.[10]

Nature-based therapies offer a multitude of empirically-supported benefits such as decreased heart rates and increased focus. In her book, Williams (2017) provides numerous evidence-based examples of nature improving the human mind and body. One study she describes, conducted by immunologist Qing Li, found that middle-aged Tokyo businessmen who spent three days in the woods experienced a 40 percent increase in natural killer cells. Natural killer cells are part of the innate immune system that limit the spread of tumors and microbial infections, thereby preventing tissue damage.[11] A month after the expedition ended, their natural killer count was “still 15 percent higher than when they started.” This study demonstrates that the positive health effects of nature are not fleeting, but can remain in the body benefiting the system long after the initial encounter.

In addition to the surplus of evidence for its health advantages, nature can also be a safe and non-judgmental place to breathe, reflect, connect, and process difficult feelings like grief. Chris Russo, a psychotherapist and ecotherapist at Seattle Anxiety Specialists, notes that everyone’s experience and relationship to nature is different. Therefore, taking time to investigate that unique relationship is a critical first step to embarking on an eco-therapeutic path. Russo adds that, “Nature can be stressful for people, so recognizing that relationship is important. Different natural environments have different effects on people.” Additionally, Russo observes that in our consumerist culture, people sometimes enter therapy looking for a “quick fix.” While research suggests that two hours a week in nature is linked to significant health benefits, Russo believes that connection with nature is more than prescriptive. He believes that “places and spaces can be coping skills in, and of, themselves,” so using therapy to explore and understand one’s current relationship with nature could help one discover a new relationship with their environment that offers a continual source of comfort or relief. 

One way Russo integrates nature with therapy is by bringing objects like pinecones and rocks to a therapy session for a client to interact with and use for reflection. He also has gone on walks in parks and observed the sounds of rushing waterfalls with clients. When asked if he felt a difference in his effectiveness as a practitioner when in nature, Russo replied, “so much of nature-based therapy is in-the-now. When we’re walking and moving along together I can be more creative than I might be in an indoor space because there is constantly new stimuli to interact with and explore.” 

Ecotherapy is not just for nature enthusiasts and wildlife lovers. Ecotherapy is for anyone who is interested in exploring their existing feelings and attitudes toward nature or through nature. It is an opportunity to investigate how society’s split from natural environments has personally impacted oneself and one’s community, and consequently affected mental well-being. It can also be a vehicle to spark conversation and memories in therapy, while at the same time bringing some of those stress-reducing and attention-boosting benefits. Time and again, empirical findings as well as TEK point to the psychological as well as physiological utility of nature. We are only just beginning to understand how the integration of nature and talk therapy can be meshed together for more profound healing, restoration, and connection than either could afford individually. 

For more information, click here to access an interview with Journalist Florence Williams on nature therapy.

Contributed by: Maya Hsu

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

References

1 Williams, F. (2018). The nature fix: Why nature makes us happier, healthier, and more creative. W.W. Norton & Company. 

2 Charles, C., & Cajete, G. A. (2020). Wisdom traditions, science and care for the earth: Pathways to responsible action. Ecopsychology, 12(2), 65–70. https://doi.org/10.1089/eco.2020.0020 

3 Whyte, K. P. (2013). On the role of traditional ecological knowledge as a collaborative concept: A philosophical study. Ecological Processes, 2(1). https://doi.org/10.1186/2192-1709-2-7  

4 Berto, R. (2014, October 21). The role of nature in coping with psycho-physiological stress: A literature review on restorativeness. Behavioral sciences (Basel, Switzerland). Retrieved November 4, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287696/. 

5 Rydstedt, L. W., & Johnsen, S. (2019). Towards an integration of recovery and restoration theories. Heliyon, 5(7), e02023. https://doi.org/10.1016/j.heliyon.2019.e02023 

6 Summers, J. K., & Vivian, D. N. (2018) Ecotherapy – A Forgotten Ecosystem Service: A Review. Front. Psychol. 9:1389. doi: 10.3389/fpsyg.2018.01389

7 Ackerman, C. E. (2021, August 1). What is Kaplan's Attention Restoration Theory (art)? benefits + criticisms. PositivePsychology.com. Retrieved November 4, 2021, from https://positivepsychology.com/attention-restoration-theory/. 

8 Kuo, F. E., & Taylor, A. F. (2004, September). A potential natural treatment for attention-deficit/hyperactivity disorder: Evidence from a national study. American journal of public health. Retrieved November 4, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448497/. 

9 Louv, R. (2005). Last child in the woods: Why children need nature, how it was taken from them, and how to get it back. Algonquin Books of Chapel Hill. 

10 Buzzell, L., & Chalquist, C. (2009). Ecotherapy: Healing with nature in mind. Sierra Club Books. 

11 Vivier, E., Tomasello, E., Baratin, M. et al. Functions of natural killer cells. Nat Immunol 9, 503–510 (2008). https://doi.org/10.1038/ni1582