Disasters and Mental Health: The Process of Recovery

An Overwhelming Sense of Loss

As families in Central Florida struggle to recover from Hurricane Ian, the Bolt Creek Fire continues burning in Washington State.[1,2] The incidence of natural disasters is on the rise, with the years 2020 and 2021 ranking as the two years with the highest recorded number of disasters in the United States.[3] Devastating disasters in 2021 included 20 billion-dollar events ranging from a derecho (a widespread, damaging windstorm that moves across vast distances) in the Midwest, an extreme cold wave event in Texas, multiple wildfires across the west coast, and four tropical cyclones in the Southeast.[4]

In 2021, the United States experienced record-smashing 20 weather or climate disasters that each resulted in at least $1 billion in damages. NOAA map by NCEI.

Image source: Smith (2022)[5]

All regions of the country are affected by some form of natural disaster and exposure to these events take a toll on mental health. In the immediate aftermath of a disaster, survivors are often left in a state of shock while struggling with anxiety over safety and recovery.[6,7] Even those who are not directly impacted by a disaster may still experience trauma due to the potential threat of their area being affected, evacuating to avoid the danger, having loved ones in harm’s way, or watching the event unfold on the news. While every person reacts to these experiences differently, it is normal for disasters to have some degree of impact on mental health.[8] Understanding these reactions, and when to seek help from others, is an important step in the process of recovery.

Common Reactions to Disasters

• Post-traumatic stress disorder (PTSD) – Post-traumatic Stress Disorder, more commonly referred to as PTSD, is the most commonly studied psychopathology following a disaster.[9] After Hurricane Maria, a sample study of survivors who relocated to Florida from Puerto Rico found that two-thirds showed significant symptoms of PTSD.[10] Those suffering from PTSD may experience flashbacks of the event, detachment from others, reactions to loud sounds, avoiding reminders of the disaster, and restless sleep from nightmares.[11] These symptoms may naturally decline over time, but a person experiencing ongoing symptoms may benefit by seeking treatment from professionals who can provide support through Cognitive Behavior Therapy (CBT) and prescribe medication if needed.[12]

• Depression – Depression is another common reaction to a disaster.[13] Symptoms of major depressive disorder, or clinical depression, may include: feeling sad, empty or hopeless; loss of interest in enjoyable activities; sleeping too much or too little; slowed thinking or speaking; feeling guilty or worthless; unexplained physical pain; increases or decreases in appetite; emotional outbursts; and thoughts of suicide.[14] A sense of loss is normal after a disaster, and these feelings may fade with time, but if symptoms last for several days, or are impeding the recovery process, it may be time to speak to a mental health professional.[15] If a person is depressed and contemplating suicide, they should seek immediate help by contacting the national suicide hotline at 988, calling 911, or proceeding to the nearest emergency room.[16]

• Anxiety – The immediate time following a disaster can be filled with fear and uncertainty of the future.[17] Disasters can activate the “flight or fight” response, which sends cortisol and adrenaline rushing through the body to help a person react more quickly.[18,19] This is a normal response to a threatening situation, and it may be difficult to differentiate between a normal rush of adrenaline following an event and the development of anxiety.[20] While occasional experiences of anxiety are considered normal throughout life (and especially following a disaster) if the symptoms persist for months, it could be a sign that a person is developing Generalized Anxiety Disorder (GAD), or another phobia-related disorder.[21] If a person begins experiencing persistent feelings of dread, worrying uncontrollably, constantly being “on-edge,” headaches, stomach aches, difficulty sleeping, or constant thoughts of a specific fear, it may be time to seek professional guidance to determine if therapy and/or medication would be beneficial.[22]

• Insomnia – Insomnia is a sleep disorder that can interfere with a person’s ability to either fall asleep or stay asleep.[23] Difficulty sleeping is common after disasters, not only because it can manifest by itself, but also because it is believed to be associated with the development of other disorders including PTSD and depression.[24] A 2019 study on survivors of disasters in Korea found that those who were widowed, divorced, elderly, separated, and in pain were the most likely to experience less than 5 hours of sleep per night in the following years.[25] If a person finds themselves experiencing insomnia, there are natural remedies that can be tried including relaxation training, stimulus control therapy, sleep environment improvement, sleep restriction, sleep hygiene, biofeedback, and remaining passively awake.[26] If these techniques do not work, it may be necessary to speak with a professional to see if medication is needed or if the insomnia may be caused by a more serious condition.

• Mood Swings – Changes in emotions are common after a disaster and may include numbness, sadness, anxiety, irritability, withdrawal, grief, helplessness, and anger.[27] Survivors often experience uncontrollable crying or bursts of anger.[28] It is important to be patient when working through grief as feelings can fluctuate, so it is normal to feel empowered one day and overwhelmed the next.[29] To help process feelings, talking to family members or loved ones may be helpful, but professional help should be sought if the feelings become overwhelming or can only be controlled with drugs or alcohol.[30]

• Solastalgia – This phenomenon describes the severing of a person from their connection to their homeland and it can arise when the landscape is changed by droughts, wildfires, or pollutants.[31] Solastalgia is a relatively new term, first created by Glen Albrecht and introduced at the Ecohealth Conference in 2003, to help describe the relationship between humans and the rapidly changing environment.[32] “The feeling of homesickness whilst still at home,” describes the feeling of longing for a home that no longer exists.[33] Though research on solastalgia is relatively new, if a person is struggling to adapt to environmental changes and is unsure of how to move forward, cognitive behavioral therapy, interpersonal therapy, psychodynamic therapy, antidepressants, and anti-anxiety medication may be beneficial when working with a mental health provider.[34]

• Ecological Grief - Ecological grief refers to the mourning that occurs when a person’s environment and lifestyles are affected by climate change.[35] While this grief may affect anyone, it is believed to disproportionately affect those who live in traditional indigenous communities and others who work with the land as part of their culture and survival.[36] Ecological grief can be associated with physical losses, but also with a loss of knowledge since teachings passed down through families for generations may no longer be applicable to the changing environment.[37] This grief can manifest as mood disorders, violence, psychiatric hospitalizations, substance abuse, emotional reactions, suicide ideation, and ecological anxiety.[38] When processing ecological grief, it is recommended to connect with others who are experiencing similar grief, look for productive ways to move forward, and find a licensed mental health provider who is trained to address climate-related concerns.[39]

• Eco-anxiety – The American Psychiatric Association describes eco-anxiety as, “a chronic fear of environmental doom.”[40] It differs from ecological grief in that it is focused on the forward-thinking practice of worrying about future environmental changes as opposed to mourning an already lost way of life.[41] Negative reactions associated with eco-anxiety include feelings of helplessness, panic, guilt, weakness, sadness, numbness, fear and anger; though at times, eco-anxiety can also have the positive effect of motivation to act.[42] While it is normal to worry about future environmental changes when recovering from a disaster, if the anxiety is severe and cannot be successfully managed at home, it may be helpful to speak with a mental health care professional or family doctor.[43]

Self-Care

While people may not be able to directly stop the natural disasters occurring in their area, they can take steps to protect their mental health. The CDC recommends getting enough sleep, eating well, exercising and avoiding harmful substances such as alcohol and tobacco.[44] After a disaster people will often feel physically and mentally drained, experience changes in sleep patterns or appetite, argue with friends and family, feel lonely, and get frustrated easily, but many of these symptoms should diminish over time.[45] The American Red Cross states that human beings are designed to be naturally resilient, so many people can find successful ways of coping.[46] Each person reacts uniquely in response to disasters, and symptoms may manifest differently,[47] but the following coping techniques have been found to be beneficial when recovering from disasters:

• Talk it Out - When families and individuals are displaced, it can affect their overall sense of community.[48] Finding someone that feels safe to talk to can help process feelings about a disaster.[49] Spending time helping others in the community (such as neighbors, family, or friends) can help to build trust and make people realize that they are not alone in their experiences.[50] It may help to look for support from others who have survived trauma in the form of a support group conducted by trained professionals.[51]

• Stay Informed - When people feel they are missing information, they may become stressed or nervous, so schedule a time to regularly get updated information from reliable sources.[52] Many organizations provide resources to deal with the effects of disasters (e.g., FEMA, The Salvation Army, and Feeding America), so make time to become educated about the resources available and what types of services are offered.[53]

• Relax - Engage in nurturing, relaxing activities that are enjoyable.[54] Relaxation exercises can include yoga, breathing exercises, listening to music, walks in nature, meditation, swimming or stretching.[55]

• Create - Creative activities can help to express feelings after a disaster.[56] These can include painting, playing music, or baking. Writing may also help to process a sense of loss or concerns about future safety.[57]

• Volunteer - Volunteering in a community is a way for a person to give back and feel they are making a positive contribution by helping others.[58] It can relieve stress by causing a person to stop thinking about their own problems for a while, put a new perspective on the situation, feel less alone, lift one’s mood, and feel better about themselves.[59]

• Exercise - Use physical exercise as a means of reducing stress.[60] Engaging in exercise, such as running, swimming, or weightlifting, can help to relieve physical tension, improve self-esteem, and regain a sense of self-control.[61]

• Eat, Hydrate & Rest - Make sure to not only eat a balanced diet, but also drink enough water to stay hydrated.[62] Get adequate rest to take a break both physically and mentally.[63] If a person finds themselves waking up at night, and unable to fall back asleep, it may be beneficial to try briefly writing about what is on their mind to process the thoughts.[64]

• Stick to a Schedule - Creating a daily schedule or routine, such as eating healthy meals and sleeping at regular times, is a way to regain a sense of normalcy.[65] Remember to schedule breaks and do things that are enjoyable.[66] Avoid constant or frequent exposure to hearing about or seeing images of the crisis because it may increase anxiety and take away attempts at returning to a sense of normalcy.[67]

• Set Goals - Setting short-term goals can help structure time and allow a person to focus on the present instead of getting lost in thought.[68] Develop a recovery plan and stick to it; focus on making progress by prioritizing which problems to tackle and breaking them down into small steps that are easy to accomplish.[69]

• Focus on the Positive - Take time to be grateful for anything that is positive in the situation instead of dwelling on the dread of what might come next.[70] Work on reframing thoughts from the negative to the positive; instead of thinking, “I can’t do this,” think, “What steps can I take to do this?”[71]

• Grieve - Grief can occur due to loss of family, friends, co-workers, job, loved ones, home, pets, possessions, or life quality.[72] Creating a ritual or ceremony to honor what was lost can help to express grief, affirm relationships/values, and move on with life.[73]

Behaviors to Avoid

Avoid negative behaviors that may give an immediate relief as opposed to dealing with the problem.[74] These behaviors include substance abuse, overworking, self-isolation, and overeating.[75] When recovering from a disaster, everyone in the area will be experiencing significant stress, so it’s important to be patient with not only yourself, but also others.[76] Anger is a normal reaction when recovering from disasters, but to preserve healthy relationships, it may be necessary to take a step back and calm down in order to think clearly.[77]

When to Seek Professional Support

The American Red Cross recommends getting professional support if any of these symptoms are experienced for two weeks or longer:[78]

• Bursts of anger

• Feeling hopeless

• Crying spells

• Loss of interest in things

• Difficulty eating or sleeping

• Fatigue

• Headaches

• Stomach aches

• Avoiding friends/family

• Feelings of guilt 

If stress from an event is impacting daily life, reach out to a doctor, counselor, therapist, psychiatrist, or clergy member for support.[79] If symptoms such as anger, insomnia, irritability, or anxiety persist, speak with a doctor or mental health provider to inquire if you should be prescribed medication, even for a short duration, following a natural disaster.[80] If symptoms do not improve, or seem to be getting worse, contact a licensed mental health professional for further guidance.[81]

Contributed by: Theresa Nair

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

REFERENCES

1 Tolan C, Devine C. Lack of flood insurance in hard-hit central florida leaves families struggling after hurricane ian. CNN Web site. https://www.cnn.com/2022/10/09/us/hurricane-ian-central-florida-flood-insurance-invs/index.html. Updated 2022. Accessed Oct 10, 2022.

2 Staff ST. Wildfire evacuations, stevens pass closure remain amid bolt creek fire. The Seattle Times Web site. https://www.seattletimes.com/seattle-news/wildfire-evacuations-stevens-pass-closure-remain-amid-bolt-creek-fire/. Updated 2022. Accessed Oct 10, 2022.

3 Smith A. 2021 U.S. billion-dollar weather and climate disasters in historical context | NOAA climate.gov. Climate.gov Web site. http://www.climate.gov/news-features/blogs/beyond-data/2021-us-billion-dollar-weather-and-climate-disasters-historical. Updated 2022. Accessed Oct 14, 2022.

4 Ibid.

5 Ibid.

6 Makwana N. Disaster and its impact on mental health: A narrative review. J Family Med Prim Care. 2019;8(10):30903095.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857396/. Accessed Oct 14, 2022. doi: 10.4103/jfmpc.jfmpc_893_19.

7 Disaster behavioral health. U.S. Department of Health & Human Services Web site. https://www.phe.gov/Preparedness/planning/abc/Pages/disaster-behavioral.aspx. Updated 2020. Accessed Oct 14, 2022.

8 Felix ED, Afifi W. THE ROLE OF SOCIAL SUPPORT ON MENTAL HEALTH AFTER MULTIPLE WILDFIRE DISASTERS: Social Support and Mental Health After Wildfires. Journal of community psychology. 2015;43(2):156-170. doi:10.1002/jcop.21671

9 Lee J, Kim S, Kim J. The impact of community disaster trauma: A focus on emerging research of PTSD and other mental health outcomes. Chonnam Med J. 2020;56(2):99-107. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250671/. Accessed Oct 14, 2022. doi: 10.4068/cmj.2020.56.2.99.

10 Espinel Z, Galea S, Kossin JP, Caban-Aleman C, Shultz JM. Climate-driven Atlantic hurricanes pose rising threats for psychopathology. The Lancet Psychiatry. 2019;6(9):721-723. doi:10.1016/S2215-0366(19)30277-9

11 Psychiatry.org - what is posttraumatic stress disorder (PTSD)?  https://www.psychiatry.org:443/patients-families/ptsd/what-is-ptsd. Updated 2020. Accessed Oct 14, 2022.

12 Ibid.

13 Stuart M. Understanding depression following a disaster. The University of Arizona Cooperative Extension Website.  https://extension.arizona.edu/sites/extension.arizona.edu/files/pubs/az1341h.pdf. Accessed Oct 14, 2022.

14 Depression (major depressive disorder) - symptoms and causes. Mayo Clinic Web site. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007. Accessed Oct 14, 2022.

15 Coping with a disaster or traumatic event. Center for Disease Control (CDC) Web site. https://emergency.cdc.gov/coping/selfcare.asp. Updated 2019. Accessed Oct 17, 2022.

16 Mayo Clinic Web (2022)

17 Coping with disaster. Mental Health America Website.  https://www.mhanational.org/coping-disaster. Accessed Oct 14, 2022.

18 Sheikh K. Natural disasters take a toll on mental health. Brain Facts Web site. https://www.brainfacts.org:443/diseases-and-disorders/mental-health/2018/natural-disasters-take-a-toll-on-mental-health-062818. Updated 2018. Accessed Oct 14, 2022.

19 Learn the difference between high anxiety and an adrenaline rush | first responder wellness. . 2022. https://www.firstresponder-wellness.com/learn-the-difference-between-high-anxiety-and-an-adrenaline-rush/. Accessed Oct 14, 2022.

20 Ibid.

21 Anxiety disorders. National Institute of Mental Health (NIMH) Website.  https://www.nimh.nih.gov/health/topics/anxiety-disorders. Accessed Oct 15, 2022.

22 Ibid.

23 Ghahari J. Insomnia. Seattle Anxiety Specialists, PLLC: Psychiatry & Psychology Web site. https://seattleanxiety.com/insomnia. Accessed Oct 15, 2022.

24 Disturbed sleep linked to mental health problems in natural disaster survivors: Study is the first to describe sleep health consequences of the 2010 earthquake in haiti. ScienceDaily Website.  https://www.sciencedaily.com/releases/2019/06/190607140446.htm. Updated 2019. Accessed Oct 15, 2022.

25 Kim Y, Lee H. Sleep problems among disaster victims: A long-term survey on the life changes of disaster victims in korea. Int J Environ Res Public Health. 2021;18(6).  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004935/. Accessed Oct 15, 2022. doi: 10.3390/ijerph18063294.

26 Ghahari (2022)

27 Stress reactions and self-care strategies after a traumatic event. Cigna Website.  https://www.cigna.com/knowledge-center/stress-after-disaster. Accessed Oct 10, 2022.

28 Taking care of your emotional health after a disaster. Red Cross Website.  https://www.redcross.org/content/dam/redcross/atg/PDF_s/Preparedness___Disaster_Recovery/General_Preparedness___Recovery/Emotional/Recovering_Emotionally_-_Large_Print.pdf. Accessed Oct 10, 2022.

29 Cigna (2022)

30 Emotional impact of disasters. txready.org Web site. https://texasready.gov/be-informed/mental-health/emotional-impact-of-disasters.html. Accessed Oct 15, 2022.

31 Kenyon G. Have you ever felt ‘solastalgia’?  https://www.bbc.com/future/article/20151030-have-you-ever-felt-solastalgia. Updated 2015. Accessed Oct 15, 2022.

32 Albrecht G, Sartore G, Connor L, et al. Solastalgia: The distress caused by environmental change. AUSTRALAS PSYCHIATRY. 2007;15:S95-S98. doi: 10.1080/10398560701701288.

33 To P, Eboreime E, Agyapong VIO. The Impact of Wildfires on Mental Health: A Scoping Review. Behavioral sciences. 2021;11(9):126-. doi:10.3390/bs11090126

34 Vanbuskirk S. What is solastalgia? Verywell Mind Website.  https://www.verywellmind.com/solastalgia-definition-symptoms-traits-causes-treatment-5089413. Updated 2021. Accessed Oct 15, 2022.

35 To et al. (2021)

36 Heid M. Ecological grief: What it is, what causes it, and how to cope. EverydayHealth.com Web site. https://www.everydayhealth.com/emotional-health/whats-the-difference-between-eco-anxiety-and-ecological-grief/. Updated 2022. Accessed Oct 15, 2022.

37 Ibid.

38 Aylward B, Cooper M, Cunsolo A. Generation climate change: Growing up with ecological grief and anxiety. Psychiatric News. 2021.  https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2021.6.20. Accessed Oct 15, 2022. doi: 10.1176/appi.pn.2021.6.20.

39 Heid (2022)

40 Huizen J. Eco-anxiety: What it is and how to manage it.  https://www.medicalnewstoday.com/articles/327354. Updated 2019. Accessed Oct 15, 2022.

41 Heid (2022)

42 Coffey et al. (2021)

43 Huizen (2019)

44 CDC (2019)

45 Red Cross (2022)

46 Ibid.

47 Kim & Lee (2021)

48 Felix & Afifi (2015)

49 Recovering emotionally from disaster. American Psychological Association Web site. https://www.apa.org/topics/disasters-response/recovering. Updated 2013. Accessed Oct 12, 2022.

50 Self-care after disasters. VA.gov | veterans affairs.  https://www.ptsd.va.gov/gethelp/disaster_selfcare.asp. Accessed Oct 10, 2022.

51 American Psychological Association (2013)

52 CDC (2019)

53 Morganstein J. Psychiatry.org - coping after disaster. American Psychiatric Association Web site. https://psychiatry.org:443/patients-families/coping-after-disaster-trauma. Updated 2019. Accessed Oct 12, 2022.

54 Cigna (2022)

55 Self care and self-help following disasters - national center for post traumatic stress disorder orange county, california. Self Care And Self-Help Following Disasters - National Center for Post Traumatic Stress Disorder Orange County, California Web site. https://orange.networkofcare.org/mh/library/article.aspx?id=3113. Accessed Oct 9, 2022.

56 American Psychological Association (2013)

57 Cigna (2022)

58 Orange County (2022)

59 Veterans Affairs (2022)

60 Cigna (2022)

61 Orange County (2022)

62 Red Cross (2022)

63 Ibid.

64 Coping tips for traumatic events and disasters. Substance Abuse and Mental Health Services Administration Web site. https://www.samhsa.gov/find-help/disaster-distress-helpline/coping-tips. Updated 2022. Accessed Oct 17, 2022.

65 Cigna (2022)

66 CDC (2019)

67 Substance Abuse and Mental Health Services Administration (2022)

68 Cigna (2022)

69 Veterans Affairs (2022)

70 Cigna (2022)

71 Veterans Affairs (2022)

72 Ibid.

73 Ibid.

74 Orange County (2022)

75 Ibid.

76  Red Cross (2022)

77 Veterans Affairs (2022)

78 Red Cross (2022)

79 CDC (2019)

80 Orange County (2022)

81 Ibid.

The Cost of Caring: Compassion Fatigue and How To Overcome It

The Dark Side of Caring for Others

Compassion is one of the foundational elements of a thriving community.[1] Helping others has numerous benefits for the self— from improvements in emotional and social wellbeing to reductions in stress, anxiety, and depression.[2,3] But is there such a thing as too much compassion?

Compassion fatigue is a specific kind of burnout that occurs after prolonged exposure to others’ trauma. It manifests as a combination of secondary traumatic stress (STS) and general burnout.[4] STS involves vicariously experiencing the emotions of others’ trauma while burnout results in feelings of exhaustion and helplessness.[5] This results in a hindered capability to be empathetic towards others’ suffering, as well as many adverse physical and emotional symptoms.[6,7] 

Mechanisms of Compassion Fatigue

There are various potential psychological mechanisms by which exposure to others’ trauma can result in the onset of compassion fatigue:[8]

1. Countertransference: Countertransference is a concept rooted in psychodynamic therapy. In psychotherapy, it refers to the therapist’s emotional reaction to the client and their experiences. This is essentially the reverse of transference, which refers to the client's emotional reaction to the therapist. Countertransference involves deep identification with the client and the fulfillment of needs through them on the part of the therapist. It is mediated by various sources, such as the therapist’s past experiences, their view of the client, and the specificities of the vicarious trauma brought on by the client’s experiences. Countertransference is seen as an issue in therapy as it can lead to biases in the way therapists provide care. [9]

2. Burnout: Burnout is a state of physical and emotional exhaustion due to prolonged exposure to situations demanding intense emotional involvement.[10] Rather than a static condition, burnout is a progression that gradually increases and worsens over time if not dealt with. It involves job stress, loss of idealism, and a feeling of helplessness and non-achievement. The main manifestation of burnout is feeling helpless in dealing with the other person’s situation. It can also lead to feelings of dehumanization.[11]

3. Emotional Contagion: Emotional contagion is an affective process that involves feeling similar emotions upon observing someone’s experiences— the specific emotional response that results may be based on the actual or expected emotions of the other person.[12] Those who view themselves as a hero or savior to others are the most likely to experience this.[13]

Presently, each of these mechanisms is studied in specific contexts. As compared to countertransference and burnout, emotional contagion is relatively infrequently cited as a mechanism of compassion fatigue. Additionally, countertransference is currently thought to be specific to the setting of therapy while the literature on burnout focuses primarily on professional settings. Emotional contagion, on the other hand, has been documented as a widespread phenomenon that can occur in almost any context involving interactions between people, from interpersonal relationships to therapy. Therefore, as noted by Figley (1995), as these mechanisms are often studied individually by different researchers, it is fairly unclear as of now how these interact to produce compassion fatigue. [14]

Who Is Affected By Compassion Fatigue?

Compassion fatigue was originally defined by Figley (1995) as “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced or suffered by a person.”[15] Therefore, it follows that people in professions that involve routinely helping others through traumatic experiences are the most susceptible to developing compassion fatigue— healthcare practitioners, social and emergency workers, and those in similar career fields.[16] In fact, the concept of compassion fatigue was originally developed to describe the feelings of people within these professions.[17]

However, even though it is far less researched in other populations, compassion fatigue can be experienced by anyone. A plethora of universal contexts exist that involve supporting others through traumatic experiences— such as leadership, relationships, parenting, etc. — and any of these can potentially bring about an episode of compassion fatigue.[18-20] 

Risk Factors for Developing Compassion Fatigue

Possessing certain qualities can put people at a higher risk of developing compassion fatigue. These include:

1. Empathy: It is well-known that trauma can occur directly through the experience of disturbing events. However, trauma can also occur indirectly, from learning about a traumatic event that happened to a close acquaintance.[21] Empathy propagates this vicarious trauma, as it involves experiencing what the other person is feeling.[22,23] Empathy therefore acts as one of the primary mechanisms of compassion fatigue as it increases the likelihood of becoming traumatized and subsequently burnt out by others’ experiences. In fact, those therapists that are most impacted by compassion fatigue are the ones who are the most effective at empathizing with and mirroring their clients’ feelings.[24]

2. Prior Traumatic Experience: Past, unresolved trauma can make one more susceptible to developing secondary trauma from listening to others’ traumatic experiences. This is particularly likely when there are similarities between the traumatic experience of both people.[25]

3. Exposure to Children’s Trauma: Suffering in children is particularly evocative of secondary trauma due to its emotional salience. Emergency workers report that they feel most susceptible to developing compassion fatigue upon witnessing children facing traumatic events.[26]

Signs & Symptoms of Compassion Fatigue

Since compassion fatigue involves both burnout and secondary traumatic stress, its symptoms can be organized based on which of these are their root cause.[27]

The symptoms caused by burnout are:[28]

• Feeling unable to help the other person

• Overwhelmed and exhausted

• Feelings of failure

• Perceived inability to do one’s job well

• Frustration

• Skepticism and loss of idealism

• Apathy and withdrawal from others

• Depression

• Substance use

The symptoms caused by secondary traumatic stress are:[29]

• Fear in situations that don’t necessarily warrant it

• Paranoia about something bad happening to the self or loved ones

• Constantly feeling on edge

• Physiological symptoms of anxiety such as high heart rate, breathlessness, and tension headaches

• Persistent, uncontrollable thoughts about others’ traumatic experiences

• Experiencing others’ trauma as if having gone through it

Compassion fatigue can also result in physiological and behavioral changes such as:[30]

• Lack of concentration

• Sleep disturbance

• Appetite changes

Compassion fatigue is sometimes difficult to distinguish from burnout since it involves the same symptoms in addition to those related to secondary traumatic stress. However, besides the fact that compassion fatigue involves additional symptoms, burnout is also distinct in that it gradually advances whereas secondary traumatic stress has a more sudden onset. Moreover, secondary traumatic stress has a faster recovery rate than burnout. Figley (1995) designed the Compassion Fatigue Self-Test for Psychotherapists to help people differentiate whether they are going through only burnout or also the additional component of secondary traumatic stress that characterizes compassion fatigue.[31,32] 

How to Overcome Compassion Fatigue

There are many strategies that individuals can adopt in order to reduce their risk of developing compassion fatigue. These include:[33]

• Keeping a healthy work-life balance

• Taking the time to practice relaxation techniques, such as meditation

• Engagement in creative activities to help with emotional expression

• Learning how and when to set boundaries

• Cognitive restructuring through routinely running through situations with a problem-solving lens

• Development of a plan for when compassion fatigue emerges

Additionally, there are myriad ways for individuals to alleviate symptoms if they are suffering from compassion fatigue. These are:[34]

• Prioritizing self-care and a healthy lifestyle that involves the right amount of exercise, diet, and sleep

• Journaling about feelings and takeaways related to caregiving

• Using stress management techniques can help ameliorate physical symptoms 

• Delegating tasks to co-workers during the recovery process

• Reflecting on successes and other positives related to providing care to others 

• Joining a support group of others going through compassion fatigue

All of these strategies essentially involve prioritizing self-care and drawing boundaries when necessary. In addition to these, seeking out professional help through counselors with specializations in trauma and its processing is also another way to alleviate compassion fatigue.[35]

The Costs of Caring Affect All of Us

Although the actual symptoms of compassion fatigue only impact the caregivers who are afflicted by it, its impacts are far more widespread than expected. Particularly within the healthcare industry, compassion fatigue has far-reaching consequences that impact not only the caregiver, but also co-workers, managers, patients, and even the healthcare system as a whole.[36,37] The performance of professionals can be severely hampered by poor judgment, frequent errors, and disconnected interactions during an episode of compassion fatigue. This leads to lower quality and less impactful care for clients. Additionally, compassion fatigue can lead to healthcare practitioners quitting their jobs. This is especially harmful to the current healthcare system, wherein there is already a lack of manpower.[38] 

As compassion fatigue can be costly to patients, professionals, and even institutions, its treatment and alleviation are key to facilitating an abundance of improvements. In order to promote well-being for all, it is important for both individuals and organizations to take the time to understand and treat compassion fatigue.[39]

Contributed by: Sanjana Bakre

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

REFERENCES

1 Lonczak, H. S. (2022, August 6). 20 reasons why compassion is so important in psychology. PositivePsychology.com. Retrieved September 12, 2022, from https://positivepsychology.com/why-is-compassion-important/#:~:text=There%20are%20numerous%20proven%20benefits,psychopathology%2C%20and%20increased%20social%20connectedness

2 Ibid.

3 Pogosyan, M. (2018, May 30). In helping others, you help yourself. Psychology Today. Retrieved September 15, 2022, from https://www.psychologytoday.com/us/blog/between-cultures/201805/in-helping-others-you-help-yourself 

4 Cocker F, Joss N (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. Int J Environ Res Public Health. 2016 Jun 22;13(6):618. doi: 10.3390/ijerph13060618. PMID: 27338436; PMCID: PMC4924075.

5 Substance Abuse and Mental Health Administration. (2014). Tips for Disaster Responders: Understanding Compassion Fatigue. Understanding Compassion Fatigue | SAMHSA Publications and Digital Products. Retrieved September 28, 2022, from https://store.samhsa.gov/product/Understanding-Compassion-Fatigue/sma14-4869 

6 Adams RE, Boscarino JA, Figley CR (2006). Compassion fatigue and psychological distress among social workers: a validation study. Am J Orthopsychiatry. 2006 Jan;76(1):103-8. doi: 10.1037/0002-9432.76.1.103. PMID: 16569133; PMCID: PMC2699394.

7 Cleveland Clinic (2021, August 29). Empathy fatigue: How it takes a toll on you. Cleveland Clinic. Retrieved September 16, 2022, from https://health.clevelandclinic.org/empathy-fatigue-how-stress-and-trauma-can-take-a-toll-on-you/ 

8 Adams et al. (2006)

9 Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge. 

10 Pines, A., & Aronson, E. (1988). Career burnout: Causes and cures. Free Press.

11 Figley (1995)

12 Miller, K. I. , Stiff, J. B. , & Ellis, B. H. (1988). Communication and empathy as precursors to burnout among human service workers. Communication Monographs , 55 (9), 336–341.

13 Figley (1995)

14 Ibid.

15 Ibid.

16 Adams et al. (2006)

17 Figley (1995)

18 Smith, D. (2022, March 30). Compassion Fatigue is real and it may be weighing you down. Harvard Business Review. Retrieved September 20, 2022, from https://hbr.org/2022/03/compassion-fatigue-is-real-and-it-may-be-weighing-you-down 

19 Koza, J. (2019, August 21). 5 signs you're experiencing compassion fatigue. One Love Foundation. Retrieved September 21, 2022, from https://www.joinonelove.org/learn/5-signs-youre-experiencing-compassion-fatigue/ 

20 Robertson, B. (2021, February 26). Preventing compassion fatigue in Foster and adoptive parents through therapeutic support and self-care. enCircle. Retrieved September 21, 2022, from https://encircleall.org/blog-2/preventing-compassion-fatigue-in-foster-and-adoptive-parents-through-therapeutic-support-and-self-care#:~:text=Compassion%20fatigue%20is%20a%20combination,apathy%2C%20exhaustion%20and%20ultimately%20burnout

21 Figley (1995)

22 Ibid.

23 American Psychological Association. (n.d.) Empathy. American Psychological Association. Retrieved September 13, 2022, from https://dictionary.apa.org/empathy

24 Figley (1995)

25 Ibid.

26 Ibid.

27 Substance Abuse and Mental Health Administration (2014)

28 Ibid.

29 Ibid.

30 Administration for Children & Families. (n.d.). Secondary Traumatic Stress. Administration for Children & Families. Retrieved September 21, 2022, from https://www.acf.hhs.gov/trauma-toolkit/secondary-traumatic-stress

31 Figley (1995)

32 Stamm, H.B. (1998). Compassion Satisfaction/Fatigue Self-Test for Helpers National Child Welfare Workforce Institute. Retrieved September 30, 2022, from https://ncwwi.org/files/Incentives__Work_Conditions/Compassion-Satisfaction-Fatigue-Self-Test.pdf

33 Administration for Children & Families (n.d.).

34 Ibid.

35 Ibid.

36 Chaudoin, K. (2020, July 27). Pandemic leads to compassion fatigue, burnout for health care workers. Lipscomb University. Retrieved September 30, 2022, from https://www.lipscomb.edu/news/pandemic-leads-compassion-fatigue-burnout-health-care-workers

37 Lombardo, B., Eyre, C., (Jan 31, 2011) "Compassion Fatigue: A Nurse’s Primer" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 3. https://doi.org/10.3912/OJIN.Vol16No01Man03 

38 Chaudoin, K (2020)

39 Ibid.

The Gut-Brain Connection: The Role of Probiotics in Maintaining Good Mental Health

You Are What You Eat

The human intestine consists of around 100 trillion bacteria that are essential for our health. The connection between the gut and brain has been proven to significantly affect people, especially those suffering from mental illness or other mental health disorders. This connection (known as bidirectional signaling) occurs as neural signals control gastrointestinal functioning; however, signaling from gut microbiota can also affect neurological functioning. Current research on the relationship between the gut and brain could impact those with mental health disorders, particularly the two most-prevalent in the U.S. (anxiety at 16.6% and depression at 28.8%).[1] 

mechanisms in the brain

The primary connection between the gut and brain involves the hypothalamic-pituitary-adrenal (HPA) axis. Through this axis, the gut microbiota can regulate levels of stress hormones such as cortisol. Vagal pathways, which are involved in the activation and regulation of the HPA axis, are the means by which the gastrointestinal tract can activate stress circuits.[2] Probiotics live microorganisms that are administered as dietary supplements or food products for health benefits have the ability to reverse the response of stress hormones being released down the HPA axis.[3] Abnormalities and hyperactivity of the HPA axis have been found to be a possible biological factor of anxiety and depression, along with other neuroanatomical abnormalities in levels of neurotransmitters (i.e., chemical substances that deliver hormonal responses in the brain).[4,5] The HPA axis is also related to depression, as depressive episodes are associated with its dysregulation and the resolution of these depressive episodes are associated with its normalization.[6] Gut microbiota are important in influencing the programming of the HPA axis in the early stages of life as well as in the reactivity of stress throughout life. 

There are several neurotransmitters affected by microbiota strains in the gut, such as norepinephrine, serotonin, and neuroendocrine. Specifically, GABA (4-aminobutanoic acid) is an inhibitory neurotransmitter in the central nervous system (CNS) that works in areas of the brain related to emotion, mood, and memory. Dysfunctions in the signaling of GABA are linked to an increase in anxiety and depression.[7] The probiotic strains of Lactobacilli and Bifidobacteria have been found to act on GABA in a similar way to antidepressants by increasing the production of GABA and reducing anxiety.[8] This demonstrates how gastrointestinal tract microflora can produce chemical changes in the brain that could regulate emotional and sensory reactions. In addition, the bacteria of the gastrointestinal tract influences CNS functioning through the neuronal activation of stress circuits. In terms of serotonin, the serotonergic system is a major component of the pathogenesis of mood disorders. There is a relationship between microbial composition and serotonin signaling, as changes in the microbiota affect the signaling systems of both serotonin and GABA in the CNS. Specifically, probiotics increased levels of tryptophan (serotonin’s precursor) thereby increasing serotonin availability in the same way as the antidepressant citalopram.[9] Wallace & Milev (2017) also showed that the administration of probiotics prevented increases in levels of norepinephrine that are induced by stress. 

the dangers of gut inflammation

The bacterial diversity of the human microbiome and inflammation of the gut have been found to be related to anxiety and depression. Stool samples of those experiencing anxiety and depression had a lower diversity in the composition of the microbial community compared to the control group (i.e., those without anxiety and depression) who had a greater diversity.[10] Microbial composition is influenced by factors such as genetic predisposition, age, nutrition, exercise, stress, and use of antibiotics.[11] In addition, the use of antibiotics has been shown to significantly decrease the microbial number and diversity in the gut.[12] Lee & Kim (2021) found that around 50% of patients with irritable bowel syndrome (IBS) have comorbid depression and/or anxiety disorder, revealing a high correlation between IBS and stress-related mental health disorders.[13] In terms of the relation of stress and probiotics to the gut microbiome, psychological stress is known to increase intestinal permeability, which allows for the entrance of harmful chemicals such as toxins and various forms of waste to enter the gut and bloodstream. The presence of pathogenic bacteria in the gut has been found to increase anxiety-like behaviors. Similarly, infection and inflammation of the gut also increase anxiety-like behaviors, via gut inflammation caused by increased intestinal permeability (i.e., “leaky gut”).[14,15]

Benefits of probiotics

Probiotics reduce intestinal permeability and inflammation by improving the integrity of the gastrointestinal lining.[16] Further, probiotics help prevent bacterial translocation that is associated with anxiety and depression.[17] Treatment of probiotics have been observed to cause a behavioral effect resembling that from the treatment of the antidepressant citalopram. This demonstrates that probiotics may have the ability to act as a form of antidepressant in a more natural way than prescription medication. Studies by Liu et al. (2019) and Chao et al. (2020) have observed lower levels of depression scores in groups that were in the probiotic condition compared to the placebo condition.[18,19] 

The implications for the psychological benefits of probiotics are significant. Given the high prevalence of anxiety and depression, probiotics offer a promising alternative to the administration of antidepressants and other psychological medications.[20] It’s important to note that if someone is currently taking prescription antidepressants, they should not lower or stop taking them unless directed to do so by their prescribing physician. In terms of implementing probiotics into one's lifestyle, significant evidence suggests that the daily consumption of a probiotic supplement can have positive psychological effects such as an increase in better mood, decrease in anxiety, and decrease in depression (particularly since anxiety is often comorbid with major depressive disorder).

beneficial probiotic foods

Alternatively, there are several fermented foods that can be implemented into one’s diet to increase probiotic intake:[21]

• Yogurt - one of the best sources of probiotics; yogurt is cultured/fermented milk that has been supplemented with active cultures that promote the growth of good bacteria in the gastrointestinal tract

• Sauerkraut - finely cut raw cabbage that has been fermented by various lactic acid bacteria

• Kefir - a tart and tangy cultured milk drink packed with various strains of beneficial probiotics and live cultures; healthiest option is the plain flavor as flavored varieties often contain added sugar; can also be added to smoothies

• Kombucha - probiotic-rich fermented drink made with tea, sugar, bacteria and yeast

• Kimchi - a spicy Korean condiment packed with lactobacilli (mentioned earlier in the article); a great addition to Asian dishes including rice, stir fries, and barbecued meats

• Miso soup - miso is fermented soy that contains healthy bacteria

• Tempeh - a good alternative to meat made with probiotic-rich fermented soybeans; this is also a healthy source of protein, fiber, and antioxidants

It is important to eat a variety of diverse probiotic foods, since each contains different types of probiotic strains, and each have different effects on the body. In addition, moderation is key in terms of probiotics, as over-consumption may lead to side effects such as bloating or digestive problems.[22] 

Before adding any supplements to one’s diet (such as probiotics), it’s always best to consult your primary care physician to inquire if probiotic supplementation will be suitable for you and confirm which dosage might be best in your case. 

Contributed by: Preeti Kota

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

REFERENCES

1 Liu, R. T., Walsh, R. F. L., & Sheehan, A. E. (2019, April 17). Prebiotics and probiotics for depression and anxiety: A systematic review and meta-analysis of controlled clinical trials. Neuroscience & Biobehavioral Reviews. Retrieved October 6, 2022, from https://www.sciencedirect.com/science/article/pii/S0149763419300533?casa_token=ken0MaMJETEAAAAA%3Azjgy9sFKvv6Yf-7-7w9IIarVfXEeDGX9aYQ21R-cwPTSQnGUVf_R9-3AwXkERA4k5Ymlpgzl

2 KA;, F. J. A. M. V. N. (n.d.). Gut-Brain Axis: How the microbiome influences anxiety and depression. Trends in neurosciences. Retrieved October 6, 2022, from https://pubmed.ncbi.nlm.nih.gov/23384445/

3 Ibid.

4 YK;, L. Y. K. (n.d.). Understanding the connection between the gut-brain axis and stress/anxiety disorders. Current psychiatry reports. Retrieved October 6, 2022, from https://pubmed.ncbi.nlm.nih.gov/33712947/

5 Wallace, C. J. K., & Milev, R. (2017, February 20). The effects of probiotics on depressive symptoms in humans: A systematic review - annals of general psychiatry. BioMed Central. Retrieved October 6, 2022, from https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-017-0138-2

6 Foster & Neufeld (2013)

7 Ibid.

8 Kane, L., & Kinzel, J. (2018). The effects of probiotics on mood and emotion. JAAPA, 31(5), 1-3. 10.1097/01.JAA.0000532122.07789.f0

9 Wallace, C. J. K., & Milev, R. (2017, February 20). The effects of probiotics on depressive symptoms in humans: A systematic review - annals of general psychiatry. BioMed Central. Retrieved October 6, 2022, from https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-017-0138-2

10 Lee & Kim (2021)

11 Ibid.

12 Foster & Neufeld (2013)

13 Lee & Kim (2021)

14 Foster & Neufeld (2013)

15 Wallace & Milev (2017)

16 Ibid.

17 Lee & Kim (2021)

18 Liu et al. (2019)

19 Chao, L., Liu, C., Sutthawongwadee, S., Li, Y., Lv, W., Chen, W., Yu, L., Zhou, J., Guo, A., Li, Z., & Guo, S. (1AD, January 1). Effects of probiotics on depressive or anxiety variables in healthy participants under stress conditions or with a depressive or anxiety diagnosis: A meta-analysis of randomized controlled trials. Frontiers. Retrieved October 6, 2022, from https://www.frontiersin.org/articles/10.3389/fneur.2020.00421/full

20 Wallace & Milev (2017)

21 How to get more probiotics. Harvard Health. (2020, August 24). Retrieved October 6, 2022, from https://www.health.harvard.edu/staying-healthy/how-to-get-more-probiotics#:~:text=The%20most%20common%20fermented%20foods,sourdough%20bread%20and%20some%20cheeses

22 Yang, S. (2022, April 22). Why cooking with probiotics might change your gut health for the better. TheThirty. Retrieved October 6, 2022, from https://thethirty.whowhatwear.com/how-to-incorporate-probiotics-into-diet/slide13  

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

School to Prison Pipeline

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

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

Zero Tolerance Policies

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

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

School Resource Officers

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

Mental health impacts within the school to prison pipeline

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

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

How do we improve?

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

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

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

Contributed by: Ariana McGeary

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

REFERENCES

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

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

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

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

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

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

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

7 Ibid.

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

9 Ibid.

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

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

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

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

13 Sawchuck, S. (2021)

14 Ibid.

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

16 Ibid.

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

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

19 Ibid.

20 Anderson, T. (2022)

21 Ibid

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

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

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

24 Ibid.

25 Ibid.

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

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

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

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

30 Ibid.

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

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

The Prevalence of Dental Anxiety

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

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

Manifestations of Dental Anxiety & Phobia

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

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

1) anxious of specific dental stimuli

2) distrust of the dental personnel

3) generalized dental anxiety

4) anxious of catastrophe.

Common fears associated with dental anxiety include:[12]

• fear of pain

• fear of blood-injury fears

• lack of trust or fear of betrayal

• fear of being ridiculed

• fear of the unknown

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

• fear of mercury poisoning

• fear of radiation exposure

• fear of choking and/or gagging

• a sense of helplessness in the dental chair

• a lack of control during dental treatment.

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

Common signs of dental phobia include:[13]

• Trouble sleeping the night before a dental appointment.

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

• Being unable to enter the dentist’s office.

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

Source: SeattleAnxiety (Instagram)

 DEVELOPMENT OF DENTAL FEAR

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

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

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

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

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

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

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

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

• dental anxiety leads to avoidance of dental care

• avoidance results in neglect of dental treatment

• neglected dental treatment leads to subsequent poor oral health

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

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

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

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

Overcoming Dental Anxiety

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

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

• psycho-therapeutic interventions

• pharmacological interventions

• a combination of both.

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

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

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

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

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

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

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

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

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

PEDIATRIC DENTAL ANXIETY

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

7 Ibid.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

34 Appukuttan (2016)

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

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

37 Appukuttan (2016)

38 Ibid.

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

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

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

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

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

44 Appukuttan (2016)

45 Ibid.

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

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

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

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

50 Cleveland Clinic

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

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

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

Narrative Therapy: Integrating Humanistic Storytelling Into Mental Healthcare

Storytelling in Medicine

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

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

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

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

Theories of Narrative Therapy

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

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

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

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

Narrative Therapy in Practice

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

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

• Deconstruction 

• Externalization

• Reauthoring

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

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

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

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

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

Benefits and Applications of Narrative Therapy

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

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

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

Limitations of Narrative Therapy

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

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

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

Contributed by: Anna Kiesewetter

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

References

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

2 Ibid.

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

4 Charon (2001)

5 Ibid. 

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

7 Roberts (2000)

8 Ibid.

9 Charon (2001)

10 Ibid. 

11 Ibid. 

12 Ibid.

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

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

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

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

17 Koganei et al. (2021)

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

19 Koganei et al. (2021)

20 Stahnke & Cooley (2022)

21 Roberts (2000)

22 Ibid.

23 Ibid. 

24 Ibid.

25 Ibid. 

26 Stahnke & Cooley (2022)

27 Tadros et al. (2022)

28 Williams-Reade et al. (2014)

29 Tadros et al. (2022)

30 Stahnke & Cooley (2022)

31 Tadros et al. (2022)

32 Stahnke & Cooley (2022)

33 Tadros et al. (2022)

34 Stahnke & Cooley (2022)

35 Roberts (2000)

36 Ibid.

37 Koganei et al. (2021)

38 Ibid.

39 Stahnke & Cooley (2022)

40 Ibid.

41 Roberts (2000)

42 Ibid.

43 Ibid.

Xenophobia and Mental Health in Asian Americans

Introduction

Although the rise of the COVID-19 pandemic has brought anti-Asian sentiments to the forefront of public consciousness, Asian Americans have long been cast as "perpetual foreigners" in a centuries-old history of discrimination.[1-3] The Trump administration's and many popular media sources' politicization of COVID-19 as the "Chinese virus" and "Kung flu," alongside the recent uptick in anti-Asian hate crimes, have only added fuel to an ongoing flame of xenophobia that dates back to the nineteenth century and has had lasting repercussions on the mental health of Asian Americans.[4]

History of Anti-Asian Racism: 1800s to Present

When the first wave of Chinese immigrants came to America during the California Gold Rush, they were harassed as foreigners who had come to take American jobs away, culminating in the signing of the Chinese Exclusion Act in 1882 which halted Chinese immigration for ten years and barred existing Chinese immigrants from naturalization.[5] During this ban, Chinese Americans were prohibited from interracial marriage and segregated into Chinatowns as the numbers of Chinese in America dwindled.[6] In the years following the ban, other Asian American groups faced yet more brutal discrimination. In 1930, Filipino American farm workers were assaulted and lynched by local California residents opposed to Asian immigration during the Watsonville Riots.[7] During World War II, hundreds of thousands of Japanese Americans were wrenched from their homes and imprisoned in internment camps across the western United States while racist caricatures circulated wartime propaganda.[8] 

Even after the doors were reopened to Chinese immigration in 1943, anti-Asian xenophobia has persisted into modern history and held a lasting impact on the mental health of Asian Americans. With the SARS (Severe Acute Respiratory Syndrome) outbreak in Asia in 2003, Asian Americans were often stereotyped as "dirty" or "disease-ridden foreigners," despite how long they had lived in the U.S.[9] These labels have resurged with the emergence of COVID-19. After the first outbreaks of the coronavirus in Wuhan, China, and its rapid spread around the globe, many Americans began scapegoating China for the pandemic. When news broke out that the disease had likely originated from an open-air wet market in Wuhan, outrage arose over the unsanitary conditions for meat and live animals that left the door open for zoonotic viral transmission.[10] This outrage snowballed into a form of hygienic racism that exacerbated stereotypes of Asian Americans as "dirty" and "disease-ridden," where tropes such as Asians "eating bats" from "filthy markets" were weaponized to shame China for practices that contributed to the pandemic.[11] With the eye of blame on China, people increasingly targeted any Asian American perceived to resemble a Chinese person, a dangerous generalization known as racial profiling that often accompanies hate speech and racial violence.[12,13] 

COVID-19 Discrimination

Startling numbers of anti-Asian hate have been reported in the two years since the pandemic began. During the first two weeks of the pandemic, 1,135 experiences of discrimination and harassment against Asian Americans were reported.[14] By December 2021, nearly two years since the pandemic's start, this number had risen to 10,905 reported hate incidents.[15] This problem has only been exacerbated throughout that time, with 42.5% of these incidents occurring in 2020 and 57.5% in 2021–a 15.2% increase.[16] Anti-Asian hate has taken many forms during the pandemic. Hate incidents have ranged from verbal harassment and xenophobic insults (such as the phrase "go back to your country"), to job discrimination and property vandalism, to being coughed on and physically assaulted.[17] 

Asian American elders are often the most vulnerable to violent attacks, and have made up the majority of prominent anti-Asian hate headlines. As reported by Bloomberg Equality, in 2020, 84-year-old Rong Xin Liao was kicked in the chest while using his walker in San Francisco. In April 2020, an attacker in New York stomped on the head of 61-year-old Yao Pan Ma, who was collecting cans. Ma died eight months later on December 31, 2020. In May of 2021, two senior Asian women were stabbed at a bus stop in downtown San Francisco after going afternoon shopping. The prevalence of these attacks can cause Asian American elders to feel frightened to leave their homes, which has led to difficulty getting necessities such as food and exercise.[18] The prolonged alienation and pain of seeing one's own elders brutally assaulted can be severely traumatic, and as put by National Alliance on Mental Illness CEO Daniel H. Gillison, Jr., the "effects of racial trauma on mental health are profound and cannot be ignored."[19]

Effects of Racism on Mental Health

Racism is extremely detrimental to mental health, and its effects are widespread in Asian American communities. A 2021 mental health report by the activist group Stop AAPI Hate revealed that 1-in-5 Asian Americans who have experienced racism display racial trauma, or severe psychological and emotional harm caused by racism. Racism and discrimination are highly correlated with stress, adverse health outcomes, and psychopathology, as well as a hesitancy to seek professional psychological help.[20] In Asian Americans, this has been seen to manifest in heightened symptoms of depression, anxiety, PTSD, suicidal ideation, and higher risk for substance abuse.[21,22] Beyond diagnosable mental health conditions, sustained discrimination can also result in more insidious harms to everyday wellbeing, including subclinical stress responses such as fear and sleep disturbances that can last for months and even years.[23] 

Being constantly demeaned as "foreign" and the cause of a disease additionally produces a form of traumatic stress that can be pervasive. The perpetuation of witnessing anti-Asian violence often leads to individuals internalizing other victims' trauma, a situation known as vicarious trauma.[24] The chronic stress and fear of endangerment resulting from vicarious trauma can predispose Asian Americans to experience long-term symptoms comparative to PTSD, such as hypervigilance, anxiety, persistent fear, anger, guilt, or shame.[25] In fact, Stop AAPI Hate's 2021 mental health report found that Asian Americans who have experienced racism feel more stressed by anti-Asian violence than about the pandemic itself, an anxiety that follows them into re-entering school and jobs as the pandemic begins to become normalized.[26] The compounding of severe xenophobia on top of a deadly pandemic burdens Asian Americans with a heavy and unjust weight to bear when their focus and energy should be centered on remaining healthy. 

Insidious Racism: Microaggressions and Gaslighting

Underlying more easily visible forms of racism are microaggressions, commonplace daily indignities that carry "hostile" or "derogatory" undercurrents toward their target, whether intentional or unintentional.[27] Microaggressions against Asian Americans tend to fall into several categories, which are by no means finite or fully independent of one another. One such category includes assumptions of inferiority, which can include statements or actions indicative of beliefs that all Asian Americans are foreigners, second class citizens, or criminals. Another category is exoticization, as evidenced by several brands, businesses, and caricatures oversexualizing Asian women.[28] Microaggressions additionally tend to ascribe to racial profiling through assumptions of similarity, making generalizations that invalidate interethnic differences (e.g., all Asians look the same; all Asians are intelligent). Other microaggressions can relate more to the environment in which they occur against Asian Americans, such as hostile comments in the workplace or school, as well as avoidance and disdain towards Asian businesses and restaurants.

Such subtle forms of discrimination can be quite insidious; because they often happen quickly (e.g., through offhand comments) and appear innocuous, it becomes difficult to react or even realize that the behavior was distressful and discriminatory.[29] In fact, the microaggression of microinvalidations gives rise to gaslighting, in both self- and societally-inflicted forms. Microinvalidations occur when Asian Americans' shared experiences of cultural friction or discrimination are discounted by others or made to seem like exaggerations–such as being told that they complain about race too much or that people of color do not experience racism anymore. Such sayings render one's experiences illegitimate and even invisible, which can lead Asian Americans to question the validity of their perceptions of reality. Doing so is a form of manipulation, i.e., gaslighting. 

Within-Group Differences

It is important to also remember that Asian Americans are not a monolith, and experiences of discrimination can compound and vary widely based on a person's unique intersection of identities. For Asian American women, anti-Asian hate has been particularly vehement: 74% of Asian American and Pacific Islander women respondents reported experiencing racism and/or discrimination over the past year, with 53% of perpetrators being a stranger, according to the National Asian Pacific American Women's Forum's 2022 State of Safety Report.[30] This number is up from previous years, with over half of women respondents reporting that they feel less safe today than when the pandemic first began and the majority of reports of discrimination being made by women.[31] 

This data additionally comes one year after the 2021 Atlanta spa shootings, where six out of eight murder victims were women of Asian American descent.[32] With the shooter's motivation cited as the "temptation" of massage parlors, Asian American women face a unique experience of hypersexualization and exoticization through the intersection of their gender and cultural identities, which renders them more susceptible to adverse mental health effects. In fact, Asian American women report more negative mental and physical outcomes than men when exposed to a lower threshold of discrimination, demonstrating the greater impact of the discriminations against their compounding identities.[33] 

Different levels of discrimination also exist based on environment. In the workplace, those without college degrees report poorer mental health scores alongside more exoticization and assumptions of similarity, while those with college degrees report more microinvalidations and workplace microaggressions.[34] Degrees are associated with different job experiences, causing different stereotypes–such as exoticism or assumption of intelligence–to become more present. Higher levels of education have also been correlated with greater perception of discrimination, due to a greater level of contact with white people as well as heightened racial awareness.[35] 

In schools, discrimination can often take the form of racial bullying, which has been on the rise with the onset of the pandemic and the spread of racist jokes about who carries the disease.[36] Racism can be particularly harmful for youth, who sit at a critical point in the development of their self-esteem and body image. When phenotypic features of Asians are ridiculed, Asian American young adults have been shown to experience body dissatisfaction and body shame, even after adjusting for controls like body mass index. The association between higher levels of racism and lower levels of self-esteem apply to ostracization as well: xenophobia often leads to exclusion of Asian Americans from social groups and activities in schools, and is shown to increase their self-consciousness, discontent, and shame about their body image.[37] 

The ostracization of Asian Americans in classrooms and workplaces often coincides with being a small minority in a class, which leads to some regional differences in experience of discrimination. In parts of the United States that have fewer Asian Americans, such as the Midwest, higher levels of microaggressions, assumptions of inferiority, exoticization, and assumptions of similarity are reported than on the West Coast.[38] This may be attributed to the fact that both the depth of Asian American history and the actual volume of Asian Americans are much greater on the West Coast than in other areas of the United States. The more familiarity and interactions with Asian Americans there are, the more harmful stereotypes are disproven and replaced with genuine relationships, an idea which could be implemented to help counter xenophobia in other areas of the U.S.[39] 

Ways to Combat Anti-Asian Hate: Culture, Therapy, and Policy

To aid in countering stereotypes, Misra & Le (2020) recommend presenting these generalizations as "unrepresentative or atypical." For example, to disprove the stereotype that individuals who look like they are from China are more likely to spread COVID-19, the media could disseminate images of Asian Americans who actively combat the spread of COVID-19 as frontline medical workers–an intervention that "has shown efficacy for reducing stigma previously."[40] In challenging social norms around race, Canady (2021) also discusses encouraging prosocial and proactive antiracism, which can include education about racial consciousness, advocacy for marginalized groups, and reactive bystander interventions. By confronting hate incidents and supporting victims afterwards, community members can foster a sense of solidarity and ease the pressures of isolation and ostracization associated with xenophobia.

For Asian Americans themselves, community can be particularly important in easing the mental burden of racial discrimination. In fact, research has found that sharing stories about one's racial discrimination experience is a protective factor for long-term traumatic stress in reaction to racial discrimination: about 28% of Asian Americans who experienced racial trauma after a hate incident no longer met criteria for race-based trauma after reporting their experience to Stop AAPI Hate.[41] It follows that it is important to openly discuss and understand the stories and histories of anti-Asian discrimination. Although disclosure can be hampered by cultural values and the minority myth, when Asian Americans are able to disclose their experiences to support groups and therapists, they are able to lift some of the burden of isolation. 

A healthy and supportive relationship with a therapist is then similarly important in navigating racial trauma. To best support Asian American clients, therapists should practice culturally competent therapy and maintain education and awareness on the intersectionality of identities.[42] Traditional Western psychological interventions tend to focus on what individual victims can and should do to combat their reactions racism, rather than "contextualizing individuals' vulnerabilities and reactions to sociocultural and structural disadvantages" in seeking broader ways to rectify the root causes of discrimination.[43] By doing so, they place a burden on individual victims who are already disadvantaged and strained by discrimination that can edge toward invalidating their experiences, gaslighting, and victim blaming. Similarly, therapists sometimes gaslight clients' experiences of racism through labeling seemingly "invisible" microaggressions that cannot be "proven" by a client as the results of being "too sensitive" or "paranoid."[44] Doing so is a microinvalidation itself that can be damaging to both the therapeutic alliance and the wellbeing of Asian American clients, demonstrating the need for therapists to cultivate cultural empathy and participate in education on culturally competent treatment.

Finally, policy interventions have the potential to enact the widespread change that individual and community actions cannot. During the SARS pandemic of 2003, the American Center for Disease Control led an initiative to counter anti-Asian sentiments by monitoring stigma in the public and media while collaborating with Asian American activists to create "culturally tailored" interventions.[45] To address the uptick in anti-Asian hate crimes, the federal government should look to the bigger picture of the long history of anti-Asian violence and enact similar interventions as in 2003. By investing in culturally appropriate mental health services and community-based outreach to the Asian American communities most affected by COVID-19 discrimination, the government can collaborate in cultivating culturally resonant responses that best combat the harm done to Asian American communities.   

Ultimately, whether overt or insidious, historical or current, anti-Asian racism has been extremely detrimental and often traumatic to the mental wellbeing of Asian American communities. In the face of the current pandemic-driven surge in anti-Asian discrimination, it is imperative to learn the history of the Asian American experience, listen to victims' stories, and foster discussion around available mental health resources. By cultivating empathy and standing up against discrimination wherever we see it, we can help build a more supportive, anti-racist, and healthy community.

If you or someone you know has experienced anti-Asian discrimination, you are not alone. You can report anti-Asian discrimination here at https://stopaapihate.org/reportincident/. 

For further mental health resources and community organizations addressing anti-Asian discrimination, please visit https://stopaapihate.org/resources/. 

For more information, click here to access an interview with Sociologist Peter J. Stein regarding genocide and discrimination.

Contributed by: Anna Kiesewetter

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

References

1 Misra, S., Le, P. D., Goldmann, E., & Yang, L. H. (2020). Psychological impact of anti-Asian stigma due to the COVID-19 pandemic: A call for research, practice, and policy responses. Psychological Trauma: Theory, Research, Practice, and Policy, 12(5), 461–464. https://doi.org/10.1037/tra0000821 
2 Nadal, K. L., Wong, Y., Sriken, J., Griffin, K., & Fujii-Doe, W. (2015). Racial microaggressions and Asian Americans: An exploratory study on within-group differences and mental health. Asian American Journal of Psychology, 6(2), 136–144. https://doi.org/10.1037/a0038058 

3 Cheng, H. L. (2020) "Xenophobia and Racism Against Asian Americans During the COVID-19 Pandemic: Mental Health Implications," Journal of Interdisciplinary Perspectives and Scholarship: Vol. 3, Article 3. https://repository.usfca.edu/jips/vol3/iss1/3 

4 Ibid.

5 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

6 Nadal et al., 2015

7 Ibid.

8 Yi, 2016

9 Misra & Le, 2020

10 Chuvileva, Y. E., Rissing, A., & King, H. B. (2020). From wet markets to Wal-Marts: tracing alimentary xenophobia in the time of COVID-19. Social anthropology: the journal of the European Association of Social Anthropologists = Anthropologie sociale, 10.1111/1469-8676.12840. Advance online publication. https://doi.org/10.1111/1469-8676.12840 

11 Ibid.

12 Misra & Le, 2020

13 Cheng, 2020

14 Misra & Le, 2020

15 Yellow Horse, A. J., Jeung, R., & Matriano, R. (2021, December 31). Stop AAPI Hate National Report. Stop AAPI Hate. Retrieved March 14, 2022, from https://stopaapihate.org/national-report-through-december-31-2021/  

16 Ibid.

17 Cheng, 2020

18 Bloomberg Equality 

19 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

20 Ibid. 

21 Misra & Le, 2020

22 Cheng, 2020

23 Nadal et al., 2015

24 Cheng, 2020

25 Ibid.

26 Saw, A., Yellow Horse, A., & Jeung, R. (2021, May 27). Stop AAPI Hate Mental Health Report. Stop AAPI Hate. Retrieved March 16, 2022, from https://stopaapihate.org/mental-health-report/ 

27 Nadal et al., 2015

28 Ibid. 

29 Ibid.

30 Pillai, D. & Lindsey, A. (2022). The State of Safety for Asian American and Pacific Islander Women in the U.S. National Asian Pacific American Women's Forum, Washington, DC. https://www.napawf.org/assets/download/napawf-state-of-safety-report.pdf 

31 Yellow Horse et al., 2021

32 Canady, 2021

33 Nadal et al., 2015

34 Ibid.

35 Ibid. 

36 Cheng, 2020

37 Ibid. 

38 Nadal et al., 2015

39 Misra & Le, 2020

40 Ibid. 

41 Saw et al., 2021

42 Canady, 2021

43 Ibid. 

44 Nadal et al., 2015

45 Misra & Le, 2020

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.