Vol 2

Strengthening Family Connections Through Therapy

Family Teamwork Makes the Dream Work

Psychotherapy provides the opportunity for families to resolve conflict, improve communication skills, and strengthen family bonds. While family therapy ideally includes all family members, it can also be conducted with those members able or willing to participate. Common goals of family therapy are to deepen family connections and learn coping skills for stressful events for both during and after therapy.[1] Family therapy is especially useful in various situations that cause stress, grief, anger, or conflict. In addition, psychotherapy can help individuals support other family members that have serious mental health issues (e.g., schizophrenia, addiction, major depression).While family therapy will not automatically solve family conflicts or make challenging situations go away, it can offer skills to cope with such situations in a more effective manner. 

Dissolving Broken Patterns 

Family therapy is often referred to as a “strengths-based treatment” due to the inclusive nature of the sessions. A family therapist will look at issues or patterns in a family dynamic that need adjusting, rather than focusing on any individual’s sole influence in the problem. Additionally, developing and maintaining healthy boundaries with family members is one common goal or benefit of family therapy that can lead towards reducing conflict.[2] Problematic family systems can reinforce distress or feelings of anger, anxiety, resentment, and sadness. It is important for a family unit to be open to attending therapy together rather than sending one “problem” individual. Jim McDonnell, a psychotherapist at Seattle Anxiety Specialists, notes that the resistance of going to therapy as a family could be the manifestation of defensiveness on the part of the parents, or the individuals avoiding therapy - and placing blame on just one person. By working collectively together, the family can increase their odds of overcoming a difficult situation.[3]

McDonnell points out that families oftentimes perpetuate patterns of response with one another that can make the situation worse. Members of a family might not intend to reinforce distress through their actions; they may be simply acting out in negative ways they’ve witnessed other family members behave or act out subconsciously. However, if problematic dynamics are not changed with the family as a whole, then individual changes will be “overturned by the culture of the family system.”[4] Therefore, openness to change is crucial for each individual in a family unit for significant results to be accomplished in therapy. 

Family Therapy Approaches

No single form of family therapy is significantly more beneficial than another. A therapist will choose a particular approach depending on the nature of the issues brought up in session. When choosing a family therapist, one should ensure that a mental health professional is properly certified and trained for the modality that fits the family needs.[5] Common approaches to family therapy include:

  • Structural Therapy - This method works to improve communication by understanding viewpoints of other family members, aims to fix broken dynamics, and encourages adjustments in problematic family functions.[6]

  • Narrative Therapy - This approach places an emphasis on personal stories related to family life and underlines that one has to become an observer and identify problems to reach solutions.[7]

  • Emotion Focused Family Therapy - Common goals of EFFT include re-establishing more secure family patterns and repairing emotional bonds by restructuring parent and child interactions.[8]

  • Transgenerational Therapy - This technique delves into family history to understand past difficulties that may predict future conflict by analyzing how separate generations can react differently to the same situations.[9]

  • Psychoeducation - This approach to family therapy aims to help those with mental health issues (and their families) to better understand conditions and equip families with coping skills to reduce symptoms and ultimately function better within the family unit.[10] 

What to Expect in Family Therapy

Family therapy is an evidence-based treatment that provides a supportive and non-judgmental environment for expressing oneself. During a family therapy session, a clinician typically asks each family member about any concerns or challenges as well as their goals and hopes for therapy.[11] Each family member will be encouraged to speak and listen to one another. If applicable, the therapist can help each family member clarify their words and feelings so everyone can better understand one another. This is especially important, because when there are communication issues, individuals might not understand the impact of their words and behaviors on other family members. In this case, the clinician can help a family work together to create positive change as well as suggest strategies for altering problematic communication styles and patterns.[12] 

Tangible Results

In certain cases, family therapists utilize activities to help identify goals among family members. For instance, one commonly-used activity in Solution-Focused Therapy is called The Miracle Question. This question simply asks clients to envision an alternate reality where relationships are improved and issues are resolved. For example, a therapist will utilize visualization with clients to induce a relaxing state to bring about awareness of an end goal.[13] This activity helps the therapist identify potential issues and create actionable goals for a family. Family therapy activities are chosen uniquely as a way to cater to each family's particular situation.[14]

When a lack of open communication exists or arguments in a home persist, a therapist might center an activity around learning to understand other family member perspectives. Jim McDonnell provides the following advice for strengthening communication among a family: “Listening is more than just hearing the words spoken by others; it is being able to observe body language, behavioral choices, words spoken, and meaning that is being made.”[15] Active listening and curious observation help a client to put themselves in the place of a family member which leads to an understanding of why one might be speaking or behaving in a certain way. Instead of fighting against other perspectives, a client can begin to see a situation from another angle and question how their own behaviors and words are influencing the conflict. 

Family therapy should be sought after when issues such as chronic mental illness or substance-abuse disorder persist and create conflict within a family. Additionally, when families experience long-term issues within communication and relationship dynamics, steps can be taken to reduce such negative experiences by contacting a licensed mental health professional for further guidance.

Contributed by: Tori Steffen

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

References

1 Mayo Foundation for Medical Education and Research. (2021, June 19). Family therapy. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/family-therapy/about/pac-20385237#:~:text=Family%20therapy%20is%20a%20type,social%20worker%20or%20licensed%20therapist.

2 MedPsych. (2021). The goals and benefits of family therapy. Comprehensive MedPsych Systems. https://www.medpsych.net/2021/01/12/the-goals-and-benefits-of-family-therapy/

3 McDonnell, Jim. (2023). Interview with Licensed Therapist & Anxiety Specialist at Seattle Anxiety Specialists, PLLC.

4 Ibid.

5 ReGain Team. (2023). Family therapy: Theories, modalities, and efficacy. Regain. https://www.regain.us/advice/family/family-therapy-theories-modalities-and-efficacy/

6 Psychology Today. (2022). Structural family therapy. Psychology Today. https://www.psychologytoday.com/us/therapy-types/structural-family-therapy

7 Clarke, J. (2022). How narrative therapy works. Verywell Mind. https://www.verywellmind.com/narrative-therapy-4172956

8 EFFT Org. (2022). Home. EFFT. https://efft.org/#about 

9 Bruhin, D. M. (2021). Types of family counseling. Apex Recovery. https://apex.rehab/treatment-therapy/types-of-family-counseling/  

10 Ibid.

11 Cleveland Clinic. (2022). Family therapy: What it is, Techniques & Types. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/24454-family-therapy 

12 Ibid.

13 Amatullah, A. (2021). The miracle question with examples, worksheets, exercises, & Demo Video. Universal Coach Institute. https://www.universalcoachinstitute.com/miracle-question/ 

14 Sutton, J. (2022). How to use the miracle question in therapy: 3 examples. PositivePsychology.com. https://positivepsychology.com/miracle-question/

15 McDonnell (2023)

Exploring the Recent Rise of Social Anxiety Disorder

The Telltale Signs

An uncomfortable flutter of the heart…sweaty palms…an uneasy turning of the stomach... Although they present with similar symptoms, experiencing anxiety and having an anxiety disorder are two different things. For example, someone might experience a jolt of nervousness when standing in a large, bustling crowd - but not every person who feels that jolt will have social anxiety disorder. While there are a variety of specific differences that set the two conditions apart, one of the main determinants is how frequently and consistently one’s anxiety is experienced. For a person to be diagnosed with social anxiety disorder (SAD), their anxiety surrounding social situations must persist for at least six months and cause them significant distress or impairment; they must also show other qualifying symptoms, such as fear that their behavior will be judged or cause them humiliation, and that social situations are either avoided or endured with great fear.[1] Notably, recent studies have found that the number of people meeting this criteria/who do have social anxiety disorder has been steadily increasing. 

THE RISE OF SOCIAL ANXIETY DISORDER

Not only is social anxiety disorder becoming increasingly common each year, its prevalence is growing fast. Approximately 15 million adults in the United States are diagnosed with social anxiety disorder every year, totaling about 7.1% of the population.[2] As staggering as that number is, it’s likely that the number of individuals afflicted with social anxiety disorder is even higher than the number of those officially diagnosed. While the afore-mentioned statistic only represents adults, social anxiety disorder is actually more common among teens and adolescents. According to the Anxiety and Depression Association of America (2022), in most cases of social anxiety disorder, the individual began experiencing symptoms when they were only around 13 years old.[3] Furthermore, 36% of those who have social anxiety disorder report that they experienced symptoms for ten years or more before seeking help.[4] Combined with the fact that many people never get their social anxiety disorder diagnosed,[5] it’s likely that the number of people with social anxiety disorder is much higher than currently on record.

Jeffries and Ungar (2020) conducted a self-reported study of nearly 7,000 individuals, aged 16-29, across seven countries selected for their cultural and economic diversity: Brazil, China, Indonesia, Russia, Thailand, the United States, and Vietnam. They found that 36% of participants met the threshold for social anxiety disorder.[6] Despite previous research showing the U.S. had a 12% lifetime prevalence rate of SAD in 2005,[7] just fifteen years later Jeffries and Ungar found that participants in the U.S. reported the highest rate of this disorder - nearly 58%. Conversely, participants in Indonesia reported the lowest rates in the study, at 22.9% (which is still remarkable at nearly 1/4 of that cohort).[8] 

It’s necessary to emphasize that Jefferies and Ungar’s study did not only ask participants whether or not they had social anxiety; they were also asked to rank statements describing common thoughts and fears experienced by those with SAD, based on how true the statement was for them. For example, statements participants were asked to rank included:[9]

  • “I get nervous if I have to speak with someone in authority.” 

  • “I feel tense if I’m alone with just one other person.” 

  • “I feel I’ll say something embarrassing when talking.” 

As such, they were not only able to consider the amount of people who recognized themselves as having SAD, but also determine how many people did not consider themselves as having SAD yet still met the benchmarks to qualify. According to their findings, 18% of those interviewed claimed that they did not have SAD, but still exceeded the threshold needed to qualify. This statistic highlights the prevalence of SAD and how people may be experiencing it, but don’t recognize it, or view themselves as someone who does not have it.[10] Possible universal reasons for this situation include: 1) a lack of understanding what SAD is and/or how it presents and 2) cognizance of a perceived lack of societal acceptance of the disorder and subsequent denial of the condition.

WHY IS IT RISING?

There is no simple answer for what’s causing social anxiety disorder to increase in prevalence the way it has been, as dozens of factors are at play. One of the most prominent among these is the rise of social media. Because social media inherently offers us so many methods for connection that don’t require any face-to-face interaction, our over-reliance on it is causing us to become more socially anxious every year.[11] This is especially relevant when it comes to younger generations, who have increasingly liberal access to social media at younger and younger ages. With this shift toward virtual interaction during stages of life where we are developing our social functioning skills and abilities, the growing prevalence of social anxiety disorder in children and adolescents seems to be a natural consequence.

Fischler (2021) notes that another potential contributor to the rise of social anxiety disorder is that, for much of the population, there is less of a pressure for survival than there have been in previous generations. While not true in every case, it is generally (comparatively) easier to access food, water, and other necessities than it has been within the last few generations. Because of this, people’s attention has tended to shift more toward material goods, since there is, at large, less concern about where the essentials will come from.[12] Fischler adds this higher emphasis on material goods, money, and social appearance have a documented link to anxiety and depressive symptoms, and thus can be linked to the increase in SAD.[13]

The recent pandemic has also contributed to the growing prevalence of SAD. Much like the increasing commonality of social media, extended quarantine situations enacted during the pandemic resulted in people either not being able to normally socialize, or having to socialize through technology, such as via Zoom meetings or social media. People have grown accustomed to not having to interact in person; now that the public is starting to open again and business are returning to on-ground work policies, many are struggling to acclimate.[14] This is especially true of children who have, to some degree, grown up in the pandemic, since they had less opportunity to socialize than children in the generations before them.[15] Medina (2021) notes it is expected that young students who are experiencing in-person education for the first time will have much higher levels of anxiety about their schooling than previous generations, mainly because of the increased socialization required.[16]

WHO DOES IT AFFECT?

While there is no one clearly defined profile for the type of person who will develop social anxiety disorder, research has found that certain demographics have a higher likelihood of developing this disorder than others. Jefferies & Ungar (2020) note that those who are unemployed, have lower educational levels, and/or live in rural areas are more-likely to present with SAD. Conversely, the prevalence rates of social anxiety disorder are the lowest in low-income countries, and the highest in high-income countries,[17] despite the fact that it’s more common in individuals who are unemployed and have lower educational levels.

Gender, too, can play a role in the development of social anxiety. Females are more likely to qualify for social anxiety disorder than males[18] and report a higher number of social fears.[19] Further, the ways in which social anxiety manifests are often also affected by gender. Women are more apt to experience social anxiety in a professional setting than men are; they’ll be more likely to be anxious about speaking to authority figures or going through the process of interviews.[20] Men, on the other hand, are more likely to have social anxiety around issues such as dating.[21] There is also a difference in comorbidity based on gender, with men more likely to have comorbid externalizing (observable) disorders, while women are more likely to have comorbid internalizing disorders.[22]

However, possibly the clearest trend in the increase in prevalence of social anxiety disorder is age. On average, younger demographics, such as children and teens, are more likely to meet the benchmark for social anxiety disorder than older adults. Jefferies & Ungar (2020) found that 90% of new cases of social anxiety were reported to have occurred by the time the individual reached 23 years old,[23] with additional contributing factors comprising a higher reliance on the individual’s family unit as well as greater emphasis on peer acceptance.[24]

HOW CAN WE TREAT IT?

In most cases, social anxiety disorder is treated through talk therapy, medication, or a combination of the two. Most commonly, cognitive behavioral therapy (CBT) is used as the primary method of treatment.[25] Through CBT, the individual learns different ways of thinking about the difficulties that they face and find different (generally more productive) ways of behaving and reacting to troubling situations. Although it isn’t a quick-fix solution, CBT is considered to be the most effective treatment option for those with social anxiety disorder. In cases where an individual is prescribed medication to help mitigate symptoms of their social anxiety, they will be in the form of antidepressants, beta blockers, or anti-anxiety medications.[26]

If you are experiencing symptoms of anxiety or social anxiety, please reach out to a licensed mental health professional for guidance and treatment options.

Contributed by: Jordan Rich

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

1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental 

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

2 Anxiety and Depression Association of America. (2022, October 28). Anxiety Disorders - Facts and Statistics. https://adaa.org/understanding-anxiety/facts-statistics

3 Ibid.

4 Ibid.

5 Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: A prevalence study in seven countries. PLoS ONE, 15(9), 1–18. https://doi-org.baypath.idm.oclc.org/10.1371/journal.pone.0239133

6 Ibid.

7 Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 62(6), 593-602. 

8 Jefferies & Ungar (2020)

9 Ibid.

10 Ibid.

11 Ibid.

12 Fischler, S. (2021). The Rise Of Anxiety Over The Past 100 Years. CBT Baltimore. 

https://www.cbtbaltimore.com/the-rise-of-anxiety-over-the-past-100-years/

13 Ibid.

14 Medina, E. (2021). How Young People’s Social Anxiety Has Worsened in the Pandemic. The New York Times. https://www.nytimes.com/2021/09/27/us/social-anxiety-pandemic.html

15 Ibid.

16 Ibid.

17 Stein, D. J., Lim, C. C. W., Roest, A. M., de Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bromet, E. J., Bruffaerts, R., de Girolamo, G., Florescu, S., Gureje, O., Haro, J. M., Harris, M. G., Yanling He, Hinkov, H., Horiguchi, I., Chiyi Hu, & Karam, A. (2017). The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative. BMC Medicine, 15, 1–21. https://doi-org.baypath.idm.oclc.org/10.1186/s12916-017-0889-2

18 Jefferies & Ungar (2020)

19 Asher, M., & Aderka, I. M. (2018). Gender differences in social anxiety disorder. Journal of Clinical Psychology, 74(10), 1730–1741. https://doi-org.baypath.idm.oclc.org/10.1002/jclp.22624

20 Ibid.

21 Ibid.

22 Ibid.

23 Jefferies & Ungar (2020)

24 Ibid.

25 National Institute of Mental Health. (2022). Social Anxiety Disorder: More Than 

Just Shynesshttps://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness

26 Ibid.

Uncovering the Connection: Mental Illness & the Homeless Crisis

To be Homeless in America

A person or family are defined as homeless when they lack a fixed, regular, and adequate nighttime residence.[1] In addition to the extreme poverty they face, the homeless are often in a struggle to be met with sympathy from the general population. In a 2019 poll of Americans taken by the CATO Institute, 42% responded that poverty is a result of a “lack of personal responsibility”.[2] While existing societal stigmas have caused many Americans to blame the homeless for their condition, several other factors must be considered.[3]

Monetary issues, in part, contribute to this mounting crisis. Three years into the pandemic, the steadily increasing costs of living and limited access to affordable housing are compounding issues for the average American.[4] But as the conversation surrounding homelessness steers towards pointing the blame at the economy, it is important not to lose sight of a factor that makes someone more vulnerable to losing their home: mental illness.[5] Public health research has long come to the resounding conclusion that homelessness and mental illness have a complex, two-way relationship that compounds challenges for those who are afflicted.[6] With the added pressure of another recession looming, mental health and homelessness have an exacerbating relationship: mental illness greatens the chances of becoming homeless, and trying to survive while homelessness takes a toll on a person’s mental health.

The Mental Illness to Homeless Pipeline

In America, approximately 4% of the general population of adults have a severe mental illness (e.g., schizophrenia, bipolar disorder, or major depressive disorder).[7] In contrast, it is estimated that 45% of the homeless population experience a form of mental illness,[8] with 25% of this population suffering from severe mental illness.[9] Unfortunately, as researchers lack sufficient access to the homeless population, the actual number of homeless people living with any form of a mental illness is potentially much higher than these annual estimates.[10]

Since the last Census in 2020, rising housing costs combined with continuous inflation for basic goods and services have left an estimated 2,000 Americans newly homeless,[11] with thousands more fearing they will soon lose their homes. In June 2022, the inflation rate hit a 41-year high of 9.1%,[12] leaving the average family strained to pay for gas, energy bills, and groceries.[13]

For those diagnosed with a mental health condition, even more challenges arise against their efforts to keep a home. Research conducted by Luciano and Merea (2010) divided over 77,000 participants into groups of “none, mild, moderate, and serious mental illness” and found that employment rates decreased with increasing mental illness.[14] Further, within the group diagnosed with “serious mental illness”, nearly 40% made an annual salary of less than $10,000”,[15] which is roughly half of the annual minimum needed for a two-bedroom apartment, according to the National Low Income Housing Coalition.[16]

While anti-discrimination laws offer protection for workers who disclose their mental illness diagnosis, many of the symptoms behind mental disorders complicate a person’s ability to maintain continuous employment. The average work week is 40 hours over the span of five days, and requires employees to show up on time, remain productive, and limit their sick leave to the numbers prescribed by their organization. But those with a mental illness are more likely to call-in sick, take medical leave, and under-perform at work.[17] As a result, individuals with a mental illness are two to three times more likely to be unemployed, with their employment rate at 15 percentage points lower than for those without mental health problems.[18]

Struggles with employment are especially relevant for people with schizophrenia, who fare poorer than any other disadvantaged group in the labor market. Individuals with this condition experience a 70-90% unemployment rate, which is roughly 30 times higher than the general population.[19] Unemployed more than any other group with disabilities, those with schizophrenia are estimated to make up 40% of the homeless population.[20] 

Lacking the ability to maintain employment, Americans with mental illnesses have a higher likelihood of unpaid medical bills and missed rent/mortgage payments.[21] Eventually, cumulating costs increase their potential of losing a place to live. 

Navigating Homelessness with a Mental Illness

It is even more difficult to overcome mental health challenges once a person becomes homeless. Lacking necessities (e.g., food, water, and hygiene) often leads to the development of worry, fear, and sleeplessness, which can then compound into mental illnesses (e.g., anxiety, depression, and substance abuse disorder) in those who may not have even had them prior to losing their home. For those that already had a diagnosis prior to losing their home, these conditions only further exacerbate their illness, and resources like medication, therapy, and hospitalization are often difficult to obtain without medical insurance. Facing relentless pressure to have basic necessities as well as gain treatment, many homeless people can barely cover the short-term costs of food, medicine, and soap,[22] and are unable to build any savings that could be used to contribute to paying rent.

Housing Discrimination

Of course, once a person becomes homeless, the natural question is: “How do they get back into a home?” Unfortunately, the compounding factors of poor mental health and lack of a steady income introduce a large barrier to owning or renting a home. When a person applies to rent a property, they are often expected to submit proof of at least six months of employment, consent to having their credit score checked, and provide information for a background check. Not only does a homeless person often have no proof of current employment, but their chances of having a low credit score from prior financial difficulties are more likely than not.[23] If they surpass these points in a renter’s application, many renters are then expected to provide a downpayment or 1.5 months’ rent for their first month. Even if an individual is eligible to rent or own a house from a financial standpoint, they may be unable to pass a background check. This predicament lands many in motels, which are non-permanent shelter, and often amount to more than the median $1,715 dollars spent monthly on rent.[24] Unable to afford motels for an extended period of time, many individuals become vulnerable to returning to living on the streets.

Adding to their difficulties, the concepts of homelessness, incarceration, and poor mental health are often inseparable. Severe mental illness is more prevalent among the homeless population and is associated with increased risk of involvement with the criminal justice system.[25] In fact, over 25% of people experiencing homelessness report being arrested for activities that are a direct result of their homelessness, such as loitering and sleeping or lying down in public spaces.[26] As aforementioned, these arrests can add to the vicious cycle facing homeless populations, as a criminal record often impacts future employment and housing opportunities. 

Not all is lost

Despite these alarming numbers, specific demographics have shown improvements in the homeless crisis in recent years, with even the most at-risk subpopulations experiencing a steady decrease in homelessness:

  • While 20% of veterans are diagnosed with PTSD in any given year, their rate of homelessness has steadily decreased 55% since 2010.[27]

  • Black Americans comprise only 13% of the U.S. population, yet make up 40% of the homeless population. However, between 2020 and 2021, the number of Black or African American people staying in shelters decreased by 12%.[28]

  • While the number of homeless families increased between the 2020 Census and 2022, the overall number of homeless independent adults dropped.[29]

  • The number of people under 25 experiencing homelessness has decreased by 12%, with youth homelessness down 6%.[30]

Further, the Federal Government continues to emplace financial interventions to support Americans with mental illness. According to a Continuing Disability Review from the Social Security Administration in 2014, mental illness is now the primary diagnosis for one-in-three persons under the age of 50 who receive disabled worker benefits.[31] As the number of disability beneficiaries with mental illness grows steadily, policy makers have an increased interest in monitoring employment rates by mental health status,[32] a sign of progress that will directly aid the homeless population.

The implications? Why does it matter

Much of the advocacy for homeless rights supports increasing the visibility of this crisis and placing additional responsibility on the general population. Since 1991, when the United Nations declared housing to be a fundamental right,[33] American society has made strides in its perception and support of the homeless population. However, mental illness is a significant hurdle to overcome, and this is often only one of a homeless person’s marginalized identities. Too often, women, people of color, and members of the LGBTQ+ community are overrepresented in the annual numbers of people without permanent housing.[34] The multiple layers of discrimination these marginalized communities combat on a daily basis also cause them to face higher barriers to reintegrate into society.

Ways We Can Help

While government intervention is key to continuing to improve the homelessness crisis, there are several ways people can continue to help:

  1. Practice Kindness & Respect: While much of the responsibility to fix discrimination against the homeless falls on policy changes, it is still within every individuals’ control to manage the ways they personally engage with homeless people. Even in small interactions with a homeless person, it is damaging to treat them as though they are invisible, or try to judge them for their state. Instead, simply saying “good morning” and treating them as though they are a normal human being have the potential to improve someone’s day. No one wants to be judged for their worst day, and the homeless are often in a unique position where they are experiencing hardship on a daily basis.

  2. Advocate Against Homelessness Discrimination: Employers are not only responsible for knowing anti-discrimination laws, but further, they must practice them in a manner that supports employees with mental illnesses and prior criminal records. It is illegal in every state to deny someone employment because of a prior felony, but employers often find work-arounds to make employment more difficult for this demographic. The “Ban the Box” campaign, which has already been implemented in 150 cities across 30 states, removed questions about criminal history from Federal job applications and pushed background checks to later in the hiring process.[35] With this change, an individual has the opportunity to be judged for other qualifications instead of being discounted over one aspect of their past. This initiative and others like it are key to combating the incarceration-to-homeless pipeline.

  3. Decriminalize Homelessness: Walking around major cities, it is often easy to find excessively slanted benches, spiked window sills, and raised grate covers, all of which all intended to keep the homeless from sheltering in public spaces. Other communities have taken measures even further, adopting laws that criminalize people for behaviors that are side effects of their survival. According to the National Homelessness Law Center, 48 states have at least one law restricting behaviors of people experiencing homelessness (e.g., loitering, trespassing, or sleeping in public spaces) and these types of laws continue to gain traction across the country.[36] Members of a community can counteract these laws through protest, by voting, and by encouraging local business owners to enact more homeless-friendly provisions.

For more programs and resources on how to help the homeless, click here.

Contributed by: Kate Campbell

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

REFERENCES

1 General definition of a homeless individual, 42 U.S.C § 11302 (1994). 

https://www.law.cornell.edu/uscode/text/42/11302#:~:text=(1),(2).

2 Ekins, E. What Americans Think About Poverty, Wealth, and Work. CATO Institute Website. https://www.cato.org/publications/survey-reports/what-americans-think-about-poverty-wealth-work. Updated 2019. Accessed February 15, 2023.

3 Ibid.

4 Homelessness: The Problem. The National Low Income Housing Coalition Website.  https://nlihc.org/explore-issues/why-we-care/problem. Updated 2023. Accessed February 12, 2023.

5 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

6 About Mental Health. Center for Disease Control and Prevention Website.  

https://www.cdc.gov/mentalhealth/learn/index.htm. Updated June 2021. Accessed February 11, 2023.

7 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

8 Ibid.

9 Ibid.

10 Ibid.

11 U.S. Department of Housing and Urban Development. (2022). Annual Homelessness Assessment Report. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. HUD Public Affairs.

12 Carter, C. With inflation at a 41-year high, USF economics professor explains what to expect. WUSF Public Media Website. 

https://wusfnews.wusf.usf.edu/economy-business/2022-07-14/inflation-41-year-high-usf-economics-professor-explains-what-to-expect. Updated July 2022. Accessed February 12, 2023.

13 Ibid.

14 Luciano A, Meara E. Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010. American Psychological Association Publishing, 2014;65(10):1-9. https://doi.org/10.1176/appi.ps.201300335.

15 Lloyd, A. Average Rent is 32% of the typical Americans’ pay; that’s more than financial experts recommend budgeting for housing. Business Insider Website.

https://www.businessinsider.in/policy/economy/news/average-rent-is-32-of-the-typical-americans-pay-thats-more-than-financial-experts-recommend-budgeting-for-housing/articleshow/90428300.cms. Updated March 2022. Accessed February 14, 2023.

16 National Low Income Housing Coalition (2022). Out of Reach: The High Cost of Living. https://nlihc.org/oor

17 How your Mental Health may be Impacting your Career. PBS Website.

https://www.pbs.org/newshour/health/how-mental-health-impacts-us-workers. Updated 2013. Accessed February 13, 2023.

18 Ibid.

19 Greenstein, L. Can Stigma Prevent Employment? National Alliance on Mental Illness Website.

https://www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment. Updated 2017. Accessed February 10, 2023.

20 Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:370.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880407/.

21 Colato EG,  Enard KE, Orban BL, Wiltshire JC.  Problems paying medical bills and mental health symptoms post-Affordable Care Act. 2022;7(2):274-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327393/

22 Fleury MJ, Grenier G, Sabetti J, et al. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLOS One. 2021;16(1). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245088. Accessed February 15, 2023.

23 Bharat N, Cicatello J, Guo E, Vallabhaneni V.  University of Michigan School of Public Health Website. https://sph.umich.edu/pursuit/2020posts/homelessness-and-job-security-challenges-and-interventions.html. Updated 2019. Accessed February 14, 2023.

24 Joint Center for Housing Studies of Harvard University. (2022). America’s Rental Housing. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_Americas_Rental_Housing_2022.pdf. 

25 Greenberg GA, Rosenheck RA. Jail Incarceration, Homelessness, and Mental Health: A National Study. Psychiatric Services. 2008;59(2):135-143.

https://doi.org/10.1176/ps.2008.59.2.170

26 Gillison, D. Veteran Mental Health: Not All Wounds are Visible. National Alliance on Mental Illness Website. https://www.nami.org/Blogs/From-the-CEO/November-2021/Veteran-Mental-Health-Not-All-Wounds-are-Visible. Updated November 2021. Accessed February 10, 2023.

27 U.S. Department of Housing and Urban Development (2022)

28 Ibid.

29 Ibid.

30 Ibid.

31 Social Security Administration. (2013). Annual Statistical Report on the Social Security Disability Insurance Program. https://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf.

32 Luciano & Meara (2014)

33 United Nations Higher Commissioner for Human Rights. (2009). The Right to Adequate Housing. (UN Publication FS 21-1). https://www.ohchr.org/sites/default/files/Documents/Publications/FS21_rev_1_Housing_en.pdf.

34 Oliva, A. Ending Homelessness: Addressing Local Challenges in Housing the Most Vulnerable. Center on Budget and Policy Priorities Website. 

https://www.cbpp.org/research/housing/ending-homelessness-addressing-local-challenges-in-housing-the-most-vulnerable. Updated 2022. Accessed February 12, 2023. 

35 Avery B, Lu H. Ban the Box: U.S. Cities, Counties, and States Adopt Fair Hiring Policies. National Employment Law Project Website. https://www.nelp.org/publication/ban-the-box-fair-chance-hiring-state-and-local-guide/. Updated 2021. Accessed February 12, 2023. 

Citations:

1 General definition of a homeless individual, 42 U.S.C § 11302 (1994). 

https://www.law.cornell.edu/uscode/text/42/11302#:~:text=(1),(2).

2 Ekins, E. What Americans Think About Poverty, Wealth, and Work. CATO Institute Website. https://www.cato.org/publications/survey-reports/what-americans-think-about-poverty-wealth-work. Updated 2019. Accessed February 15, 2023.

3 Ibid.

4 Homelessness: The Problem. The National Low Income Housing Coalition Website.  https://nlihc.org/explore-issues/why-we-care/problem. Updated 2023. Accessed February 12, 2023.

5 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

6 About Mental Health. Center for Disease Control and Prevention Website.  

https://www.cdc.gov/mentalhealth/learn/index.htm. Updated June 2021. Accessed February 11, 2023.

7 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

8 Ibid.

9 Ibid.

10 Ibid.

11 U.S. Department of Housing and Urban Development. (2022). Annual Homelessness Assessment Report. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. HUD Public Affairs.

12 Carter, C. With inflation at a 41-year high, USF economics professor explains what to expect. WUSF Public Media Website. 

https://wusfnews.wusf.usf.edu/economy-business/2022-07-14/inflation-41-year-high-usf-economics-professor-explains-what-to-expect. Updated July 2022. Accessed February 12, 2023.

13 Ibid.

14 Luciano A, Meara E. Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010. American Psychological Association Publishing, 2014;65(10):1-9. https://doi.org/10.1176/appi.ps.201300335.

15 Lloyd, A. Average Rent is 32% of the typical Americans’ pay; that’s more than financial experts recommend budgeting for housing. Business Insider Website.

https://www.businessinsider.in/policy/economy/news/average-rent-is-32-of-the-typical-americans-pay-thats-more-than-financial-experts-recommend-budgeting-for-housing/articleshow/90428300.cms. Updated March 2022. Accessed February 14, 2023.

16 National Low Income Housing Coalition (2022). Out of Reach: The High Cost of Living. https://nlihc.org/oor

17 How your Mental Health may be Impacting your Career. PBS Website.

https://www.pbs.org/newshour/health/how-mental-health-impacts-us-workers. Updated 2013. Accessed February 13, 2023.

18 Ibid.

19 Greenstein, L. Can Stigma Prevent Employment? National Alliance on Mental Illness Website.

https://www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment. Updated 2017. Accessed February 10, 2023.

20 Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:370.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880407/.

21 Colato EG,  Enard KE, Orban BL, Wiltshire JC.  Problems paying medical bills and mental health symptoms post-Affordable Care Act. 2022;7(2):274-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327393/

22 Fleury MJ, Grenier G, Sabetti J, et al. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLOS One. 2021;16(1). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245088. Accessed February 15, 2023.

23 Bharat N, Cicatello J, Guo E, Vallabhaneni V.  University of Michigan School of Public Health Website. https://sph.umich.edu/pursuit/2020posts/homelessness-and-job-security-challenges-and-interventions.html. Updated 2019. Accessed February 14, 2023.

24 Joint Center for Housing Studies of Harvard University. (2022). America’s Rental Housing. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_Americas_Rental_Housing_2022.pdf. 

25 Greenberg GA, Rosenheck RA. Jail Incarceration, Homelessness, and Mental Health: A National Study. Psychiatric Services. 2008;59(2):135-143.

https://doi.org/10.1176/ps.2008.59.2.170

26 Gillison, D. Veteran Mental Health: Not All Wounds are Visible. National Alliance on Mental Illness Website. https://www.nami.org/Blogs/From-the-CEO/November-2021/Veteran-Mental-Health-Not-All-Wounds-are-Visible. Updated November 2021. Accessed February 10, 2023.

27 U.S. Department of Housing and Urban Development (2022)

28 Ibid.

29 Ibid.

30 Ibid.

31 Social Security Administration. (2013). Annual Statistical Report on the Social Security Disability Insurance Program. https://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf.

32 Luciano & Meara (2014)

33 United Nations Higher Commissioner for Human Rights. (2009). The Right to Adequate Housing. (UN Publication FS 21-1). https://www.ohchr.org/sites/default/files/Documents/Publications/FS21_rev_1_Housing_en.pdf.

34 Oliva, A. Ending Homelessness: Addressing Local Challenges in Housing the Most Vulnerable. Center on Budget and Policy Priorities Website. 

https://www.cbpp.org/research/housing/ending-homelessness-addressing-local-challenges-in-housing-the-most-vulnerable. Updated 2022. Accessed February 12, 2023. 

35 Avery B, Lu H. Ban the Box: U.S. Cities, Counties, and States Adopt Fair Hiring Policies. National Employment Law Project Website. https://www.nelp.org/publication/ban-the-box-fair-chance-hiring-state-and-local-guide/. Updated 2021. Accessed February 12, 2023. 

36 National Homelessness Law Center. (2021). Housing not Handcuffs 2021: State Law Supplement. https://homelesslaw.org/wp-content/uploads/2021/11/2021-HNH-State-Crim-Supplement.pdf.

Brain Changes in Autism Spectrum Disorder: Emerging Research & Potential Treatments

Expanding Our Understanding of ASD

Over the past year, new research emerged that deepened the scientific community’s understanding of brain changes in autism spectrum disorder (ASD). In 2018, the National Institute of Health (NIH) estimated that among eight-year-old children in the United States, 1 in 44 are diagnosed with ASD (males 3 to 4 times more likely to be diagnosed than females).[1] Since those with ASD often struggle with ongoing social difficulties throughout life, the latest studies may provide insights and implications for ground-breaking potential treatments.

Study 1: Vocal Prosody

Vocal prosody refers to changes in speech that include volume variations, stress patterns, pauses, intonation, and rhythm.[2] These types of verbal emotional cues are an important aspect of child development, and the inability to pick up on them is considered a prominent component of ASD behavior. There are currently two theories explaining why individuals with ASD have difficulty with verbal cues.[3] The sensory deficit model proposes that the auditory regions of the brain are processing sounds differently when an individual has ASD.[4] A second theory uses social cognition to hypothesize that individuals with autism process auditory sounds normally, but then interpret them differently in the social regions of the brain.[5]

 A recent study conducted by Stanford School of Medicine used MRI brain scans to show that both children with autism and a neurotypical control group used the auditory processing region of the brain when listening to voices– but there were differences in how the signal reached the social region of the brain.[6] This supports the social cognitive approach that the auditory processing in both groups is the same, but that sounds are then interpreted differently by individuals with ASD.[7]

Researchers believe that they may now be able to incorporate this knowledge into techniques for treatment. Dr. Simon Leipold, one of the authors of the study, explains these findings indicate that, “the temporoparietal junction might be a promising brain region to target” when looking at future treatments.[8] For example, it is possible that techniques previously examined by Stanford Medicine to help ASD children recognize facial expressions may now be applied to accurately identifying vocal cues.[9]

Study 2: Changes in the Cerebral Cortex

A study led by UCLA found that brain changes in those diagnosed with autism are more pervasive than previously realized.[10] Gandal et al., (2022) conducted RNA sequencing analysis to evaluate differences in 11 distinct brain regions by matching samples from individuals with idiopathic ASD to neurotypical controls.[11] The researchers found changes in all 11 cortical regions, indicating widespread differences at the molecular level.[12] Until this study, it was previously believed that brain changes in ASD only took place in the specific regions believed to affect language and behavior.[13] 

These comprehensive findings are the result of more than a decade of research which culminated in developing a full analysis of the autistic brain.[14] Further, Gandal et al., determined the largest differences were found in the visual and parietal cortex, which may help explain the sensory hypersensitivity that is often reported by individuals with ASD. Dr. Daniel Geschwind, a professor of Human Genetics, Neurology and Psychiatry at UCLA who authored the study, stated that these findings can now serve as a starting point to develop new pharmaceutical therapies that specifically address these mechanisms.[15]  

Study 3: Neuroinflammation

Neuroinflammation is an immune response that takes place in the central nervous system, and it is believed to be activated by infection, psychological stress, toxins, trauma, aging, and ischemia.[16] Though neuroinflammation does have normal function during the processes of protection and repair, acute or chronic inflammation can result in altered behavior and cognition.[17] A recent study of 1,275 immune genes showed atypical expression patterns that varied by condition in the brains of adults diagnosed with: autism; depression; bipolar disorder; schizophrenia; Parkinson’s disease; and/or Alzheimer’s disease.[18] 

Lead researcher, Dr. Chunyu Liu, explains these expressions are “signatures” for each diagnosis that could potentially be used as markers of inflammation, indicating the immune system may be a “major player” in brain disorders.[19] However, from the current study, it is not possible to tell whether these conditions altered immune activation or whether immune activations contributed to the development of these conditions.[20]

The brains of those diagnosed with autism specifically showed 275 genes with varied expression levels compared to controls, with autistic males presenting more variation than autistic females.[21] This study’s analysis also found that ASD was clustered more closely with the neurological disorders of Alzheimer’s Disease and Parkinson’s Disease than psychiatric conditions such as major depressive disorder, bipolar disorder, or schizophrenia.[22] Chen et al., note these findings indicate that different types of immune-related treatment strategies may be needed for different clusters of diseases.[23]

Study 4: Differences Among Males & Females

There are new indications that autism may shift the brain towards typically male characteristics.[24] To evaluate this question, Floris et al., conducted research predicting the sex of a brain based on brain images and found that the accuracy of sex prediction was higher for autistic males compared to both autistic females and neurotypical males. More accurate predictions were also found in adults than children, indicating these differences may vary throughout developmental stages. Specifically, researchers found that visual and auditory processing areas normally associated with facial and speech recognition indicated a shift towards male brain structure. A comparison of neurotypical and autistic female brains further reinforced this idea, with autistic females showing sensory pathways that are normally seen in neurotypical males. This finding supports sensory-based theories which suggest that early disruptions to motor and sensory processing may lead to some of the social symptoms seen in ASD.[25]

It is also important to note that a similar test conducted on the brains of those diagnosed with attention deficit hyperactivity disorder (ADHD) did not produce the same results.[26] This research by Floris et al., furthers the biological understanding of ASD and creates the groundwork for a deeper understanding of differences in ASD between sexes.[27]

Study 5: Genetic Mutation

A seven-year study conducted by Rutgers University analyzed a gene mutation in ASD known as R451C in the gene Neurologin-3.[28] Prior to this research, studies on the mutation in the synapses of mice indicated there was a causative relationship between the mutation and the pathophysiology of ASD, but it was not clear if these findings could be extended to humans.[29] Wang et al., (2022) conducted this study with the goal of understanding whether the mutation would have a similar effect on the function of synapses in human neurons.[30]

The research team used CRISPR (a unique gene editing technology) to alter the genetic material of human stem cells and derive human neuron cells, which carried the mutation they wanted to analyze.[31] They then implanted human cells both with and without the mutation into the brains of mice to compare the results.[32] Evidence from their research showed a burst of electrical activity (indicating an overstimulation) in the mutated genes which was more than double what was observed in the non-mutated cells.[33] The results were consistent with earlier hypotheses and indicate there may be a physiological path between increased excitatory synaptic activity and the development of ASD.[34] Senior author of this study, Dr. Zhiping Pang, hopes that the unique techniques developed to perform this experiment will be used by future researchers to not only conduct further studies on mental disorders, but also potentially develop new therapeutics.[35]

Study 6: Phelan-McDermid Syndrome

A team of researchers at Northwestern University Feinberg School of Medicine, led by Dr. Peter Penzes, developed a new therapy to treat a subtype of ASD, known as Phelan-McDermid syndrome (PMS). PMS, a rare genetic condition, is known to be caused by a specific mutation within the SHANK3 gene that is characterized by epilepsy, global developmental delay, and absent or delayed speech.[36,37]

Rohman (2022) notes the team developed a derivative of an insulin-like growth factor-binding protein (IGFBP2) that was previously shown to improve cognitive functions and neuroplasticity.[38] Researchers administered the derived peptide (JB2) to mice with similar mutations and evaluated the results with brain imaging.[39] The treatment showed improvement in ultrasonic vocalization, learning, memory, synaptic function and plasticity, and motor functions in addition to normalizing seizure susceptibility and neuronal excitability.[40] Dr. Penzes believes this study may lead to a pediatric treatment that could be used to address symptoms while the brain is developing, though acknowledges it is difficult to get revolutionary types of treatment approved.[41]

The afore-mentioned studies conducted over the past year illustrate significant gains in the scientific understanding of ASD. As technologies such as CRISPR become more commonplace, the potential exists to develop new biomarkers to diagnose ASD and develop novel treatments that can intervene early in the process of development by addressing the root cause of symptoms. These studies serve to clarify our understanding of the unique needs of individuals with autism and provide hope for families in the future.

Contributed by: Theresa Nair

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

REFERENCES

1 Autism spectrum disorder (ASD). National Institute of Mental Health (NIMH) Web site. https://www.nimh.nih.gov/health/statistics/autism-spectrum-disorder-asd. Updated 2022. Accessed Feb 4, 2023.

2 Meredith A. Prosody and articulation. Apraxia Kids Web site. https://www.apraxia-kids.org/apraxia_kids_library/prosody-and-articulation/. Accessed Feb 4, 2023.

3 Leipold S, Abrams DA, Karraker S, Phillips JM, Menon V. Aberrant emotional prosody circuitry predicts social communication impairments in children with autism. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. 2022. https://www.sciencedirect.com/science/article/pii/S2451902222002452. doi: 10.1016/j.bpsc.2022.09.016.

4 Digitale E. Brain wiring explains why autism hinders grasp of vocal emotion, says stanford medicine study. News Center Web site. http://med.stanford.edu/news/all-news/2023/01/brain-autism-speech-emotion.html. Updated 2023. Accessed Jan 20, 2023.

5 Digitale (2023)

6 Ibid.

7 Leipold et al. (2022)

8 Digitale (2023)

9 Ibid.

10 Brain changes in autism are far more sweeping than previously known, study finds: The study is the most comprehensive effort yet to study how autism affects the brain at the molecular level -- ScienceDaily. Science Daily. 2022. https://www.sciencedaily.com/releases/2022/11/221102123603.htm. Accessed Jan 17, 2023.

11 Gandal MJ, Haney JR, Wamsley B, et al. Broad transcriptomic dysregulation occurs across the cerebral cortex in ASD. Nature. 2022;611(7936):532-539. https://www.nature.com/articles/s41586-022-05377-7. Accessed Jan 18, 2023. doi: 10.1038/s41586-022-05377-7.

12 SD (2022)

13 Ibid.

14 Ibid.

15 Ibid.

16 Chen Y, Dai J, Tang L, et al. Neuroimmune transcriptome changes in patient brains of psychiatric and neurological disorders. Mol Psychiatry. 2022. doi: 10.1038/s41380-022-01854-7.

17 Ibid.

18 Dattaro L. Immunity-linked genes expressed differently in brains of autistic people. Spectrum | Autism Research News Web site. https://www.spectrumnews.org/news/immunity-linked-genes-expressed-differently-in-brains-of-autistic-people/. Updated 2023. Accessed Jan 21, 2023.

19 Ibid.

20 Ibid.

21 Ibid.

22 Chen et al. (2022)

23 Ibid.

24 Hernandez L. Sex-differential neuroanatomy in autism: A shift toward male-characteristic brain structure | american journal of psychiatry. . 2023. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.20220939. Accessed Jan 20, 2023.

25 Ibid.

26 Ibid.

27 Ibid.

28 MacPherson K. Gene mutation leading to autism found to overstimulate brain cells. Rutgers | The State University of New Jersey Web site. https://www.rutgers.edu/news/gene-mutation-leading-autism-found-overstimulate-brain-cells. Updated 2022. Accessed Jan 29, 2023.

29 Wang L, Mirabella VR, Dai R, et al. Analyses of the autism-associated neuroligin-3 R451C mutation in human neurons reveal a gain-of-function synaptic mechanism. Mol Psychiatry. 2022:1-16. https://www.nature.com/articles/s41380-022-01834-x. Accessed Jan 29, 2023. doi: 10.1038/s41380-022-01834-x.

30 Ibid.

31 MacPherson (2022)

32 Ibid.

33 Ibid.

34 Wang et al. (2022)

35 MacPherson (2022)

36 Rohman M. Northwestern investigators develop new therapy for autism subtype. Northwestern Medicine News Center Web site. https://news.feinberg.northwestern.edu/2022/12/26/northwestern-investigators-develop-new-therapy-for-autism-subtype/. Updated 2022. Accessed Jan 21, 2023.

37 Burgdorf JS, Yoon S, Dos Santos M, Lammert CR, Moskal JR, Penzes P. An IGFBP2-derived peptide promotes neuroplasticity and rescues deficits in a mouse model of phelan-McDermid syndrome. Mol Psychiatry. 2022:1-11. https://www.nature.com/articles/s41380-022-01904-0. Accessed Jan 25, 2023. doi: 10.1038/s41380-022-01904-0.

38 Rohman (2022)

39 Ibid.

40 Burgdorf et al. (2022)

41 Rohman (2022)

The Surprising Impact of Pets on Our Mental Health

Can Pets Really Benefit Our Mental Health?

The idea that pets improve our mental health and wellbeing is a thought that has been around for centuries. But surprisingly, this claim’s entrance into the scientific world is relatively new.[1] From lowering stress and hypertension to increasing perceived social support and daily positive affect, pets really do seem to be “man’s best friend”.[2] There are many anecdotal cases supporting the effectiveness of pet companionship as treatment for mental health conditions— in fact, Cusack (1998) notes pets have even been prescribed to patients as ‘co-therapists’.[3] However, despite the overwhelming narrative support for this idea, the empirical findings are mixed.[4] 

Due to this topic’s recent breakthrough into the scientific world, datasets have generally been fairly limited in their size, making their proper analysis and summary difficult. Moreover, a lack of random sampling, difficulties in controlling confounding variables, and unreliability in the measurement of subjective variables have all made it difficult to correctly distill generalizable and reliable causal relationships from these studies.[5] But, fortunately for our furry, feathered, and scaled friends, despite these discrepancies in quantitative empirical research, there seem to be many potential mechanisms by which our pets can improve our wellbeing. And the research is only increasing in volume.[6] 


Mechanisms by Which Pets Can Improve Mental Health

In daily life: 

Interacting with an animal can help reduce stress in both the short-term as well as the long-term. Freund et al., (2016) note that the presence of an animal has an instant soothing effect on many people, reducing autonomic stress indicators such as blood pressure and heart rate.[7] Moreover, the oxytocin released during human-animal interactions helps down-regulate the HPA axis, the primary mechanism of stress reactions in humans. This results in lowered cortisol levels, leading to lowered stress in the long-term, as well.[8,9] Lowered stress, in addition to increased levels of physical activity intrinsic to owning pets, results in improved emotional wellbeing as well as a reduced risk of heart disease.[10,11] 

Relatedly, animals act as an important source of social support for people, much in the same way that other humans do. Social relationships are one of the main regulators of affect in humans— in fact, loneliness negatively impacts both psychological and biological processes, from cognitive function to autonomic system sensitivity and hormonal levels. Additionally, oxytocin not only helps reduce stress but also simultaneously promotes positive feelings of security and comfort. Therefore, pets are able to boost emotional wellbeing by alleviating feelings of stress and promoting positive affect in their role as reliable sources of social connection for many people.[12]

In child development:

Animals also play an important part in the development of key cognitive and emotional skills in children. Interactions with animals are chock full of novel experiences and cognitive challenges for children. Aspects of pet ownership, such as gradual, repetitive training and incremental demands, are known to improve the development of skills such as planning, shifting attention, and impulse control in children. The sense of responsibility imparted by caring for a pet in the household also allows children to further these important developmental skills. Furthermore, living with a pet can help enhance emotional intelligence, empathy, and social skills in children. The task of providing sustenance, play, and care to a pet provides a plethora of opportunities to engage in safe, non-stressful social interactions as well as a deeper understanding of how to care for another being.[13]

In supporting those with mental health conditions:

Pet ownership can help alleviate symptoms of many mental health conditions by providing emotional support in a unique way to subvert negative affect. Pets are sentient; many pets’ ability to provide affection as well as their intuition to provide support when it is needed allows them to help people through symptomatic episodes. Relatedly, pets are able to reduce feelings of loneliness by acting as a consistent source of affiliation and physical touch. In a study by Brooks (2018), pets were even shown to help people create new social connections and strengthen existing ones. Since feeling isolated is both a propagator as well as a byproduct of many mental health conditions such as depression and personality disorders, pets are able to greatly improve patients’ daily lives in this way.[14]

In addition to providing emotional support, the unconditionally positive regard with which a pet may view its owner helps to promote positive self-image, which is often diminished in many mental health conditions. Pets can make people feel accepted for their entire self as well as proud about their role as a caretaker. In this way, pets can help promote self-esteem and self-acceptance, helping to subvert stigma associated with mental health conditions. This unconditional acceptance also allows for people to verbalize their thoughts and express their emotions without fear of judgment to their pets. This can help people with emotional regulation, stress resilience, and perseverance through difficult life events. Pets help provide relationships that are free of stressors like conflict, betrayal, or crossing of boundaries, which create safe spaces for people with conditions such as PTSD or Autism.[15]

Beyond providing emotional support and the potential for boundless affection, pets also provide a welcome distraction from symptoms. Pets have been found to subvert key symptoms such as suicidal ideation, hallucinations, and panic attacks simply by being present and redirecting patients’ attention. Moreover, by creating routines, increasing physical exercise, and constantly requiring care, pets are able to alleviate negative mental health symptoms by promoting healthy habits and providing something positive for people to focus on.[16]


The Eternal Question: Dog or Cat? Or Bird or Fish or…?

The majority of anecdotal as well as empirical evidence suggest that dogs have the greatest positive impact on people’s emotional wellbeing as compared to cats or any other kind of animal. Certain genetic characteristics of dogs make them better suited to the role of support animals by making them more trainable and affectionate than other animals.[17,18] Additionally, dog owners tend to score better across all aspects of emotional wellbeing than cat owners.[19] 

However, this discrepancy may be found in the fact that there is currently far less research regarding the health benefits of cat ownership than dogs. The field is continuing to grow and cats are being found to have similar impacts on human emotional wellbeing as dogs. An article shared by UC Davis Veterinary Medicine notes that cats are able to form similarly deep emotional bonds with humans and those with more extroverted tendencies are able to benefit their owners as much as dogs.[20] 

However, despite the focus of research and narratives on just dogs and cats, other animals are also able to confer similar benefits to humans’ mental health.[21] Animals such as snakes, rabbits, birds, and horses can also improve people’s daily lives in similar ways.[22,23] The best companion animal is one that is highly individualized and unique to match each person’s personality, lifestyle, and attachment style.[24-26]

“Munchkin” Photo credit: Sanjana Bakre


So What’s The Verdict?

Finally, after considering all the evidence: do pets improve our mental health or not? The answer is… maybe. 

Although the quantitative data is quite lacking, there is a large archive of qualitative data as well as individual case studies that support the claim that pets can have life-changing impacts on our mental health.[27,28] The lacuna in quantitative data can be attributed to the fact that this topic has only recently begun to be researched seriously.[29] The proliferation of supporting qualitative data is promising and future research into this topic could prove to be revolutionizing to wellbeing interventions for both clinical populations as well as the general public.[30]

The answer to this question is also a very subjective one. Although pets can boost wellbeing in myriad different ways, prescribing a pet to someone who doesn’t have the mental bandwidth or physical resources to take care of an animal could do far more harm than good.[31] It is also strongly recommended to ensure, that before getting any type of pet, everyone in the household is on the same page about pet ownership and responsibilities and that they do research beforehand to know what is fully required in terms of cost and proper care to ensure both the animal and family remain happy and healthy. So yes, a pet can truly change someone’s life for the better— but it is not a panacea or a one-size-fits-all cure.

Contributed by: Sanjana Bakre

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

References

1 Cusack, O. (1988). Pets and Mental Health (1st ed.). Routledge. https://doi.org/10.4324/9781315784618

2 U.S. Department of Health and Human Services. (2022, July 26). The power of pets. National Institutes of Health. Retrieved January 31, 2023, from https://newsinhealth.nih.gov/2018/02/power-pets

3 Cusack (1988)

4 U.S. Department of Health and Human Services (2022)

5 Koivusilta, L. K., & Ojanlatva, A. (2006). To have or not to have a pet for better health? PLoS ONE, 1(1). https://doi.org/10.1371/journal.pone.0000109

6 Cusack (1988)

7 Freund, McCune, S., Esposito, L., Gee, N. R., & McCardle, P. (2016). The social neuroscience of human-animal interaction. American Psychological Association. https://doi.org/10.1037/14856-000

8 U.S. Department of Health and Human Services (2022)

9 Freund et al. (2016)

10 U.S. Department of Health and Human Services (2022)

11 American Heart Association. (2022, July 19). Pets as coworkers. www.heart.org. Retrieved January 31, 2023, from https://www.heart.org/en/healthy-living/healthy-bond-for-life-pets/pets-as-coworkers 

12 Freund et al. (2016)

13 Ibid.

14 Brooks, H.L., Rushton, K., Lovell, K. et al. The power of support from companion animals for people living with mental health problems: a systematic review and narrative synthesis of the evidence. BMC Psychiatry 18, 31 (2018). https://doi.org/10.1186/s12888-018-1613-2

15 Ibid.

16 Ibid.

17 Freund et al. (2016)

18 Wood, T. (2020, December 5). Why therapy cats are just as effective as therapy dogs. School of Veterinary Medicine. Retrieved January 31, 2023, from https://www.vetmed.ucdavis.edu/news/why-therapy-cats-are-just-effective-therapy-dogs

19 Bao, K.J., Schreer, G. (2016) Pets and Happiness: Examining the Association between Pet Ownership and Wellbeing, Anthrozoös, 29:2, 283-296, DOI: 10.1080/08927936.2016.1152721

20 Wood (2020)

21 Brooks, A. C. (2021, August 11). Which pet will make you happiest? The Atlantic. Retrieved January 31, 2023, from https://www.theatlantic.com/family/archive/2021/08/choosing-pet-happiness/619663/

22 Granger, A. (2022, July 5). What animals can be emotional support animals? Therapy Pets Unlimited. Retrieved January 31, 2023, from https://therapypetsunlimited.org/what-animals-can-be-emotional-support-animals/

23 Granger, A. (2022, July 5). Can a snake be an emotional support animal? Therapy Pets Unlimited. Retrieved January 31, 2023, from https://therapypetsunlimited.org/can-a-snake-be-an-emotional-support-animal/#:~:text=If%20you%20are%20looking%20for,playing%20or%20caring%20for%20them

24 Brooks, A.C. (2021)

25 Samuel D. Gosling, Carson J. Sandy & Jeff Potter (2010) Personalities of Self-Identified “Dog People” and “Cat People”, Anthrozoös, 23:3, 213-222, DOI: 10.2752/175303710X12750451258850

26 Simring, K. S. (2015, September 1). What your pet reveals about you. Scientific American. Retrieved January 31, 2023, from https://www.scientificamerican.com/article/what-your-pet-reveals-about-you1/ 

27 Cusack (1988)

28 Koivusilta (2006)

29 Ibid.

30 Cusack (1988)

31 Brooks (2018)

Perceptions of Play: A Theoretical/Qualitative Discussion on the Necessity and Manifestations of Play

Introductory Op-Ed

Something that I have noticed as I have moved through adult and clinical spaces is that adults do not play, nor is it prioritized as an important part of our lives. Play in adulthood is a concept that is worth exploring, especially as it relates to increasing levels of burnout in working adults. For an extremely burnt-out generation of adults, there needs to be a remedy that both alleviates the effects of burnout and safeguards against future instability. Play is an activity that, from a clinical standpoint, reduces stress levels in the body and correlates to better qualities of life. From a social and more philosophical standpoint, play is a connective event that guides a person to see the imaginative possibilities in front of them. Imagination, joy, and hope are all parts of ourselves that play bolsters. My question concerning play is one that comes from the belief that joy is healing and that such joy is in of itself revolutionary. Drawing from Ross Gay’s exploration into daily joy in The Book of Delights and bell hooks’ analysis of love as both a salve and deconstructive tool in All About Love, I ask, what does prioritizing joy through the tangible act of playing look like? What does play give us access to? Rather than making the burden of understanding and identifying play’s potentials a solely individual responsibility to discover and figure out, I wanted to see what clinicians themselves had to say on the matter. With the perspective that therapy and healing are communal events that draw from the experiences of both client and clinician alike, it is important to me to consider this specific perspective.

METHODology

I conducted an online survey announced through therapist groups on social media, with a series of questions asking respondents to reflect on play in their personal lives as well as in their clinical practices. The phrasing of these questions were intentionally open-ended so that participants were free to interpret play as it relates to them. Conducting a survey on play in an open-ended and non-defined inquiry method allowed me access to experiences and theories I would have otherwise been completely blind to. Allowing the definition of what “play” itself signifies to remain undefined or asking people to reflect and report on their experience of play in their own lives without scales were decisions I made intentionally, for the act of taking this survey might be itself an exercise in play. Were I to delineate any specific mode in which I was imagining play, the lush horizon of what a participant could consider as play would be harshly limited. Keeping in mind the critiques of clinical analysis that stem from a critique of rigidity and inaccessibility, this survey was in of itself an exercise in playing with inquiry that opened the space for stories and anecdotes from playing clinicians. 

I asked clinicians working in Seattle to take time and reflect on their experience of play inside and outside of their clinical rooms. I created a survey split into two sections (personal and clinical), asking participants to describe what play looks like and what they notice happens as a result of play in these realms of experience. In the first section regarding play in a participant’s personal life, I asked them to self-report on how much they felt they currently played on a scale from 1 (none at all) to 10 (multiple times a day), and then I asked them to describe a specific time they remembered playing. I asked similar questions in the clinical section, inquiring into whether participants felt they tried to incorporate play into their sessions and what a specific moment looked like. I received a total of eight responses, and will use selected quotations from those submissions below.

Data/Discussion

Play in Clinicians’ Personal Spheres

After asking people to think about how much they felt they played in their personal lives with the intention of opening the door to deeply thinking about play, I asked people to tell me about what play looks like to them and about a specific memory. While some people were pretty succinct in their answers, they gave glimpses into a variety of playful moments. One person responded with a small list of their playful acts: “Writing, cooking, baking, skipping.” Compared to other responses, this answer is considerably shorter and simpler. Skipping itself is not a game that has rules or a form of play that comes with a set of expectations or goals; rather, skipping is fundamentally about movement. The whole “goal” of skipping is to play with movement itself and to do so with joy. Had I defined play and presented this participant with any single conception, this person may not have even given themselves room to consider skipping as a consideration nor would I have been able to experience the joy of knowing this person skips.

Play in the simple and lived present was a theme I noted throughout reading these responses, as others too noticed that the play in their lives existed in moments of movement and spontaneity. One person recalled a memory of their morning walk in which they passed by a jungle gym and ultimately played on it. “It was fast and definitely made me woozy,” they said after remarking on the type of equipment they played on. Another admitted that play is difficult for them, saying “I don’t always think of what I do as play. Last week, I called a friend to meet me for an impromptu walk. She has a 4-year-old who joined us. We played while we walked around the park.” This person did not specify what form this play in the park took, just that it occurred while in motion and with others. The simplicity of this memory leaves a lot for us to imagine, but it is not hard to envision the spontaneity a child can bring to something as normal as a walk in the park. In all three of these responses, these participants seem to happen upon play, or rather, play happened upon them. Within moments in which they were least expecting it and most likely not searching for play, they found something within themselves and their environments that inspired an excursion, a diversion from the norm, an adventure! 

One other theme running through many responses was the centrality of community and relationship in peoples’ recollection of play. One such respondent described their conception of play with an anecdote about a moment between themselves and their partner:

“Being silly or spontaneous or creative. I love to surprise (but not scare) a laugh out of people, or support healing with humor.

More specifically? I had a break at work so I bought my wife something special for lunch, brought it home (she works from home), and arranged it on the kitchen counter for her to find on her lunch break 15 minutes later.”

For this person, play takes the form of a connective moment between themselves and their wife, one that does not necessarily involve a specific game or script but purely the element of kind surprise. What makes this moment playful is the irony of one person knowing something another does not and using fun to connect, which is not something we often think of when we try to define play. This anecdote may stand as an example of how the action of being in community with others may be an act of play all by itself, for it is through our interactions with others that we somewhat step out of our hard shells. Many others noted that their play involved other people in their lives, whether that be children/family or friends, and I am keen to make note of the way in which other people bring about or make up the space for play in our lives. One person said play looks like “being silly with [their] cat and partner” or “playing games with online friends,” leaving up to our interpretation what “silly” means or what constitutes these games. Another participant described play in a few words, saying “goofing around with my son this morning.” One simply just responded, “with my infant and toddler…” without a description of what occurred between them and their children. For these people, their connection to another person (or being, in the case of pets) was enough to encapsulate what play meant to them, so much so that they did not feel the need to go into any specifics. Instead, they seemed to say, here we were together, we did something together, and what we did brought me joy. For these participants, play takes on the form of connection, of quality time, of loving another person. Play is not necessarily a highly individualized and independent action; it may even be inherently social. 

A final and somewhat unexpected theme was the percentage of responses that included something along the lines of table-top roleplay games (TTRPGs) like Dungeons & Dragons (DnD) or video games. In their answer, one participant simply named such games as “imagination play” while two others specifically named DnD, the increasingly popular tabletop roleplay game. Two responses mentioned some form of online or video games, and one named general board games as part of their play as well. To play in such a way requires immense imaginative capabilities, as this type of play asks the player to purely be in an entirely different manner. In taking on the character of a being existing in an entirely different realm than our own, these people begin to fully embody the play itself. Especially for those players who, when playing, use accents or cultural habits different to their own, such imaginative play asks a player to step completely outside of themselves and into someone new.

After asking people to recall a moment of play in their personal lives, I asked people if they noticed any changes in themselves as a result. Specifically, I asked participants, “did you notice any changes in yourself, emotional or physical, as a result of this play?” A few people recalled feeling lighter and “[getting] outside of [their] brain for a bit” as a result of play, while others specifically recorded feeling recharged in some way. The feeling of being weighed down or even held down is common for those experiencing intense stress or struggling with their mental health. From this place, future plans even as far as the next step feel burdened and impossible. For these participants, play acted as a way of revitalizing, a way of re-accessing energy and life to move through the next moments with renewed energy or outlooks. Other responses noted the feeling of being happier, of smiling, of feeling “a bit more ‘fun’ inside” when they played. Two answers touched on the joy of slowing down, of becoming “less rigid and goal-oriented, less linear” after their moments of play. As adults, we are sometimes asked to choose between what is practical and what makes us happy. In some cases, someone may not even have a choice but must do what will best support themselves or their communities. Play may be antithetical to a world that forces people to sacrifice joy for survival by letting joy exist even in the smallest moments. We may not have the answer to creating an entirely new world in which people do not have to choose surviving over thriving yet, but play may bring us to a place where imagining such a world is more possible.

Play in Clinicians’ Professional Spheres

After asking people to recall play in their personal lives, I specifically shifted the conversation towards play in participants’ clinical lives, starting with simply asking participants if they intentionally try to incorporate play into their therapeutic sessions. The majority of clinicians reported yes, they do try to intentionally play in their therapeutic spaces, although what form this play takes varies. A couple respondents reported that they integrated play into the general organization of the session itself, rather than as a distinct event. One respondent said, “I like to take the formality (not professionalism) out of therapy, so my office is about getting comfy,” and described the ways in which they try to invite their clients to play with environmental tools. In these instances, play becomes a way of inherently experiencing the therapeutic space as a playful and familiar space, so that the space itself becomes a source of comfort. A few respondents also reported that they aim to intertwine humor into their conversations with clients, both for themselves and for their clients’ sakes. One respondent said they preferred “using humor to address uncomfortable topics” with their clients and making assignments “playful” in what feels to be an effort to make the therapeutic conversation more accessible. Another person said, “I love to laugh with clients” and that if they can laugh with their clients about anything, then “that feels playful,” while another clinician mentioned “gently teasing clients and being open to being teased.” In these sessions, humor becomes an invitation into the therapeutic space as well as a processing tool that encourages both clinician and client to engage with the subject of the session in a playful manner.

A few people described play in their sessions as some distinct form of creative or artistic event offered to their client. For these clinicians, the play they brought in was a separate activity for their clients to do alongside therapeutic conversation. One such activity was “creating and decorating a worry box” for one clinician. For the clinician who reported that they try to make their space a source of comfort, they gave the following example:

“My client let me teach them how to make a string bracelet (like what some people call a friendship bracelet). We spent a lot of session just working on it back and forth together.”

This playful activity acts as a bridge between client and clinician and helped make the clinician a source of comfort for the client as well. Play in this instance took the form of connection and bonding, so that the very tie between client and clinician was filled with play. One clinician who reported being trained in therapeutically applied TTRPGs said that they incorporate games and other forms of play therapy into their sessions.

While most clinicians who responded to this survey were able to pinpoint and describe some form of play in their practice, one person responded saying they do not intentionally bring play into their sessions as they “don’t have the training to feel comfortable with play.” It is intriguing to classify play as something that necessitates training, which implies a level of standardized rigor or structure. This is not to say that there are no unhealthy forms of play and every form of play in a clinical space is beneficial, however the concept of play as a specific modality raises a question about how we define play. Perhaps the definition of play in certain clinical spaces is too narrow, and this conception of play makes playing in the clinical space unachievable for these clinicians. Considering that this response included the notion of comfort in playing, it is interesting to think about what makes a clinician uncomfortable or lack confidence in bringing play into their sessions. When we view play as an act or event, which is therefore something that can be practiced or developed, a lack of confidence here may point to an underlying lack of support for the development of play in clinical development. To be clear, this is not a negative reflection on these clinicians, but more a critical inquiry into clinical definitions of play.

At this point, I asked clinicians to similarly reflect on whether they noticed any changes in their clients as a result of this play. Many of the responses stated that clients generally felt “more open” and “more engaged” after play as though play took the form of a respite or reinvigoration in the midst of hard work. In these sessions, play became a source of energy with which to continue the conversation or to explore concepts more deeply. For the clinician who described the playful act of making friendship bracelets with their client, they mused that play “helped [clients] build trust in [them]” as clients felt more able to “be clumsy” and then “get better” at something with their clinician. This clinician even noted that “they felt really proud to wear the bracelet” after making them. For this clinician and their client, play acted not only as a healing activity but a prerequisite to healing conversation, without which this clinician may not have been able to connect and work with their client at the level needed. In almost every response to this question, clinicians reported some kind of reinforced and bolstered connection between themselves and their client or between their client and the healing work.

After reflecting on any changes they may have observed in their clients, I asked clinicians to reflect specifically on changes they may have noticed in themselves as a result of play in their clinical spaces. These responses described similar observations to those of the changes observed in their clients, as a few clinicians responded saying they felt a reprieve from the heaviness of session, ranging from responses saying play made the session “feel less heavy” to being “emotionally rewarding” for the clinician themselves. These responses give us an insight to the emotional weight held by the clinicians when endeavoring to work with clients and encourages us not to forget that healing work is a two-way street and one that requires full engagement from both client and clinician. Play, then, is not only important for the health of the client but also for the wellbeing of the clinician, on which a lot of responsibility rests. Additionally, play may act as a cathartic release within the clinical space itself, such that clears the air between clinician and client and allows them to genuinely meet. Another main theme running through the responses to this question revolved around connection and trust between the clinician and their client. One respondent answered this question by saying that play “took some of the pressure off [them] to ‘build trust’” with their client. Another responded by saying that play in session “helps [them] relate as people” to their clients. Play in these moments became a way of humanizing the clinicians for their clients, enabling them to be accessible and comforting sources of healing for these clients. One clinician simply stated that playing in session made them feel like they and their client “are on the same level when we play.” For therapeutic work, which may often seem daunting or cold to clients, play is not only a tool for healing but also a tool for making space for healing. 

Conclusions

It may sometimes be easier to sit behind the curtain and expound on what play could mean theoretically for us, but to think on play purely from a theoretical perspective blocks us off from play itself. To think about play, to imagine what play is, to remember and keep play alive in our lives - these are all ways of playing as well. I asked people to recall a memory of play to open their minds back up to a moment in which play was fully available and accessible. I asked them to tell me about this memory to make the play stronger by bringing another person into it, by allowing it to live in another moment. It is important to ask ourselves to come back down to the ground and think about play from a truly practical and tangible perspective, because then we can see how available play is to us. 

The themes running throughout these responses are not themes wholly devoid from our lives: spontaneity, curiosity, connection, love. They may be harder to reach or make room for in our highly structured and regulated lives, but they are not extinct. If we can recognize that the fundamental building blocks of play can be things as basic as spontaneity or love, we can find an entire world of play at our fingertips. One participant perfectly encapsulated this in their response to the question about whether play changed anything inside of them. They simply responded, “I’m not sure. This is just how I am! :)” In the entirety of this survey, no answer made me pause as long as this one did, nor did any one make me smile as hard. It is not difficult to imagine that this respondent smiled as they wrote this, and my own smile mirrors theirs while reading it. In their answer, they embody being playful, they embody the experience of living in the moment, of connecting, of caring. his person may be able to see play in more moments when they hold the components for play in themselves at any given moment. One other response from a clinician seems especially poignant in this final reflection, as they said “I believe play looks and feels different for each person. It also evolves as they find healing.” Play is not something stagnant and monolithic but vibrantly human and something that is constantly shifting. With this response, the question stops being “how do we play?” but perhaps morphs into something closer to “how do we stay playful?”

Contributed by: Neha Hazra

Editors: Jennifer (Ghahari) Smith, Ph.D. and Jerome Veith, Ph.D.


Appenix

* The following survey was referenced in the article above:

Clinicians & Play Survey Questionnaire

This survey invites you to elaborate on what role play holds in your personal life and clinical work. It is part of a larger project inquiring into play as an avenue for healing in adults. The survey is not based in a specific definition of play, so you are encouraged to respond according to your own resonances. For this reason, your descriptions in qualitative portions will be especially useful. If a question does not apply to you, please indicate this. There will be two sets of questions, each with its own area of focus.

Play in Personal Life:

1. On a scale from 1 (none at all) to 10 (multiple times a day/every day), rate how much you feel you play currently in your own life.

2. What does play look like in your life? Describe a time you can remember playing recently.

3. Did you notice any changes in yourself, emotional or physical, as a result of this play?

Play in Clinical Life:

4. Do you intentionally try to incorporate some form of play into your therapeutic sessions?

  • Yes

  • No

  • I’m not sure

5. What does play look like in your practice? Describe a time you can remember playing during a session.

6. Did you notice any changes in your client, emotional or physical, as a result of this play?

7. Did you notice any changes in yourself, emotional or physical, as a result of this play?

8. If any, what modalities do you primarily work in?

Revamping the Conversation on Love Languages

“What’s your love language?” is a Pigeonhole

As a quick and simple way to try and glean compatibility or greater understanding of another, it has become trendy to ask people the question, “What’s your love language?” In order to talk about love languages in a way that builds deeper connection and understanding, the question we should really be asking is “Which love languages do you speak and what is your favorite to communicate in?” Investigating the interactive patterns we fall into as a society allows us to identify areas in which we can strengthen the quality of our relationships and our overall health and well-being.[1-3]

The love languages so ubiquitously recognized today were introduced in 1992 by a Southern Baptist Pastor, Gary Chapman, who wrote mostly for an audience of married Christian couples. What has been lost from Chapman’s original texts as his book rose to widespread fame, is his urging toward learning to communicate in other people’s love languages.[4]

There are several issues with the way in which people broach the contemporary conversation about love languages, starting with the oversimplicity of the well-known question: “What’s your love language?” People often feel compelled to answer with one-- maybe two-- of the five options:[5] 

  • Quality time 

  • Acts of service 

  • Physical touch 

  • Words of affirmation 

  • Gift giving  

As a result of having to identify one singular language, their significant others may begin expressing affection in one singular way; a pigeonhole effect emerges and context is no longer considered. This is a loss because the way in which we communicate and behave is always impacted by our context; so, the way in which we each want to receive love probably shifts depending on circumstances, too.

A Tangent on Gift Giving

Of the five popularized love languages, it’s often most unpopular to say that one’s love language is gift giving-- it can sound shallow, frivolous, and meaningless. In actuality, gift giving is as legitimate and communicative a love language as any other. Gift giving does not have to mean your loved ones are running out to buy you a new watch or the latest iPhone, slapping a bow on it, and declaring your need for love fulfilled. Gift giving can look like your mom going grocery shopping, stumbling upon a new item that has candied almonds-- your favorite-- and buying them because she’s excited to make your day better. It can look like your roommate remembering that you mentioned you needed new sheets and then ordering them for you in your favorite color because they know you’re too stressed to deal with that yourself right now. And, it could be your partner picking up the latest iphone, putting a bow on it, and giving it to you because your current phone battery doesn’t last more than two hours. 

Gift giving can be incredibly thoughtful, nurturing, connecting, and kind. It shows that you’re alive in people’s minds and hearts even when you’re not physically together; it shows that they were thinking of you and wanted you to feel their care, so they bought something to symbolize their desire for your happiness and wellbeing. Shankar Vedantam, the host of the Hidden Brain podcast, interviewed Jeff Galak (a Professor of Marketing at Carnegie Mellon University) about the secret of gift giving. Galak shared that he and his wife have kept an ongoing google doc for 12 years with items they’d like to one day receive or acquire. With this list, they eliminate the guessing inherent in much of our gift giving norms and are empowered to reliably purchase gifts for each other with complete certainty it will make the other happy. Galak reports success with this method, as neither joy nor surprise are extinguished as a consequence to explicitly recording what they want.[6]

The Multiplicity of Expression

Some people do not find it comforting to have a hand on their back when feeling sad. They may also find it irritating or unpleasant to hug others. That’s okay. Physical touch is generally not how they like to receive or show care. Some people have an extremely difficult time accepting compliments or do not feel supported by verbal validation. Words of affirmation probably tend to fall flat for them. Some people find that the bedrock of a good relationship is to have time together where both parties are fully present and undistracted by screens (i.e., quality time)… and also need physical touch and acts of service to feel seen and cared for. For many, there isn’t as clear a distinction between the categories as their different labels might imply. As an example, some people might define quality time as time spent cuddling or touching. Some of the languages might overlap or be part and parcel of each other. 

There also exist people who feel comfortable and capable of communicating love in any and all of the five Chapman ways. The manner in which they choose to express themselves on a given day or in a given moment can depend on their mood, energy levels, financial situation, and who they are with. To ask a person, “What is your love language?” is to force that person to place the five options into a hierarchical ranking that fails to capture the complexity of the ways that person likes to receive and spread love. The question compels someone to have to select a single method of expressing love (out of an actual multitude of nuanced ways) above the rest. By having to whittle away the rich and important aspects of communicating love in order to give the questioner an extremely digestible response, with which they are likely using to simply sprinkle more of into the relationship, all of the depth and potential for greater understanding of one another is lost. 

A Richer Conversation

Therefore, it is extremely limiting to ask someone to identify their one love language. Due to the fact that there are people who are versed in multiple languages and find joy in some, most, or all of the five (however that looks for them), more illuminating and exploratory avenues of conversation would be:

  • The languages expressed around them growing up; what languages did they learn from their parents/ caregivers?

  • Which situations do they prefer an emphasis on one language over another? 

  • Which languages, if any, they struggle to feel safe or seen in; do any just never resonate?

  • Which languages, if any, do they want to learn or are trying to become more fluent in?

  • Which ones they like to receive more than give, or give more than receive (potential follow up question: how did that unidirectionality come to be?)

The Question About Love Languages Is Merely a Starting Point

While it makes sense that people would assume utility in the love language question as a concrete determinant of compatibility, research findings have been mixed. Ashley Fetters, a former staff writer at The Atlantic, explains that “If you sit down and read Chapman’s book, it’s clear that the love language you’re meant to think about isn’t your own, but your partner’s.”[7] The rushed way in which people discuss love languages today reflects an intention to find a partner with the same language, or at least to find someone willing to communicate in their preferred ones. We have lost sight of Chapman’s mission in having this conversation-- which was to learn how to express love in the language of the other-- in order to expedite the process of assessing compatibility. One study that tested the hypothesis that couples with the same love language would report higher relationship satisfaction found that self-regulatory behaviors had a greater impact on relationship satisfaction than having aligned languages.[8]

The ambiguity of the five terms also typically goes un-probed and assumed; what does “quality time” or “words of affirmation” even mean, if not explicated on an individual and personal level? By accepting an interlocutor’s answer at face value, one is projecting their own definition of those phrases onto the other, without learning what it means to them. A simple remedy for that is to ask the follow up question: What does that mean to you?/ What does that look like for you? Asking another about love language(s) is useful as a starting point, rather than as a conclusion. 

The various styles in which we crave tenderness also begs a bigger conversation about the importance of relying on community for love and support, rather than just one’s primary partner. It can be burdensome, unrealistic, and unsustainable to expect one’s romantic partner to fulfill all of one’s needs. Love languages are relevant not just to the romantic realm, but the platonic and familial realms as well. Communication and expression are requisite for building and maintaining strong relationships while nurturing good mental health. The ways in which we give and receive love impact all relationships, and therefore are worthy of consideration in a much more expanded and thoughtful sense than society currently does.

Contributed by: Maya Hsu

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

REFERENCES

1 Canavello, A. & Crocker, J. (2010). Creating good relationships: Responsiveness, Relationship Quality, and Interpersonal Goals. Journal of personality and social psychology, 99(1), 78-106. https://doi.org/10.1037/a0018186

2 Downs, V. C. & Javidi, M. (2009). Linking communication motives to loneliness in the lives of older adults: An empirical test of interpersonal needs and gratifications. Journal of Applied Communication Research 18(1), 32-48. https://doi.org/10.1080/00909889009360313

3 Yanguas, J., Pinazo-Henandis, S., & Tarazona-Santabalbina, F. J. (2018). The complexity of loneliness. Acta bio-medica: Atenei Parmensis, 89(2), 302-314. https://doi.org/10.23750/abm.v89i2.7404

4 Fetter, A. (2017). It isn’t about your love language; it’s about your partner’s. The Atlantic, https://www.theatlantic.com/family/archive/2019/10/how-the-five-love-languages-gets-misinterpreted/600283/

5 Chapman, G. D. (1995). The five love languages: How to express heartfelt commitment to your mate. Northfield Publishing. 

6 Vedantam, S. (Host). (2022). The secret to gift giving [Audio podcast episode]. In Hidden Brain. NPR. https://hiddenbrain.org/podcast/the-secret-to-gift-giving/

7 Fetter, A. (2017)

8 Bunt, S. & Hazelwood, Z. J. (2017). Walking the walk, talking the talk: Love languages, self-regulation, and relationship satisfaction. Personal Relationships 24(2), 280-290. https://doi.org/10.1111/pere.12182 

Alcohol & Anxiety: A Vicious Cycle

Comorbidity: Grounds for Investigation

Alcohol use and anxiety disorders are commonly comorbid, with alcoholics prone to experiencing symptoms of anxiety compared to the general population.[1] Schuckit & Hesselbrock (1994) report that 2 out of every 3 alcoholics possess the criteria to be diagnosed for another psychiatric disorder, such as anxiety.[2] There are explanations for both directions of the relationship, as people with anxiety may be using alcohol to feel better but alcohol could also lead to anxiety. In other words, anxiety disorders can cause alcohol abuse, and symptoms of anxiety are key aspects of alcohol dependence, particularly during withdrawal.[3] Although the etiology of the relationship between alcohol and anxiety is not clear, there is a link. Understanding the mechanisms behind the link between alcohol and the onset of anxiety can allow for the development of new solutions for stress and alcohol-related disorders. 

ADOLESCENTS AT RISK

Alcohol is the most commonly used drug among adolescents and this cohort is also more likely to experience alcohol abuse and dependence.[4] This is significant as adolescence is an important period in brain development during which critical regions of the brain (such as the prefrontal cortex (PFC), responsible for cognition and executive functioning) are still developing.[5] This process of brain development leaves adolescents vulnerable to psychological disorders such as anxiety, and drinking alcohol could exacerbate symptoms of anxiety and/or negatively affect brain development. 

UNDERSTANDING THE LINK

Several regions of the brain are implicated in the relationship between alcoholism and anxiety, particularly the PFC and the amygdala. The PFC relays information to the amygdala, which has important implications in pathologic behavior states.[6] The functional connectivity between the PFC and amygdala is crucial for several major psychological processes such as the regulation of emotions and stress. Hyperactivity and hyperreactivity of the amygdala are important measures of anxiety disorders. In particular, the central amygdala (CeA) is a primary component in the regulation of stress and anxiety. The CeA is the major output region in the amygdala and is part of the larger extended amygdala, a network of limbic forebrain structures, which is involved in the transition to alcohol dependence.[7] The CeA transforms emotional and sensory information into physiological and behavioral responses. Specifically, the signaling of the hormone corticotropin releasing factor (CRF) in the amygdala plays a significant role in anxiety as it is a prostress peptide, meaning it promotes anxiety-like behavior.[8,9] Injections of CRF into the amygdala lead to anxiety-like behaviors; therefore reducing levels of this hormone may alleviate anxiety.[10] Similarly, the CeA is a critical region involved in alcohol addiction and the negative reinforcement of alcohol abstinence.[11] Dysregulation of CRF signaling can therefore influence the development of alcoholism. 

Dysfunction in the amygdala is associated with both anxiety and substance abuse disorders. Acute and chronic exposure to alcohol have significant effects on synaptic transmission (signaling between neurons) in the amygdala, a key region of stress and anxiety circuitry.[12] This commonality of the involvement of the amygdala in both anxiety and alcoholism suggests a connection between the two disorders. Alcohol has been found to increase stress sensitivity from neurological changes in the amygdala.[13] For instance, CRF is a neuropeptide involved in the stress circuits that regulate anxiety associated with drug dependence. This hormone contributes to the regulation of anxiety and alcohol-related behaviors and thus plays an important role between anxiety and the neurological effects of alcohol consumption. A study by Silberman (2009) found that the release of CRF in the CeA increases in animals that are alcohol-dependent and contributes to anxiety resulting from alcohol-withdrawal.[14] This demonstrates that CRF is the mediating factor between dependence on alcohol and anxiety produced, as drinking alcohol increases the production of CRF in the amygdala, which consequently increases stress and anxiety. CRF plays a critical role in regulating negative affect and excessive alcohol drinking via the CeA.[15] Gilpen et al. (2012) found that binge drinking in dependent and non-dependent adolescent rats produces lasting neural and behavioral changes implicated in anxiety and alcohol use disorders.[16] 

IMPLICATIONS FOR SOLUTIONS

It would be beneficial for scientists to further examine the role of the amygdala in anxiety and alcohol consumption, especially in terms of seeking novel treatment options. Since anxiety is a key factor resulting from alcohol withdrawal that often leads to relapse, targeting this anxiety could prevent relapse. Pharmacologic approaches (e.g., developing drugs or medications that target CRF production) could alleviate the anxiety associated with alcohol consumption, which could help alcoholics recover rather than drinking more to alleviate anxiety; it could also prevent people from developing alcoholism by avoiding excessive drinking. Additionally, it could also prevent people from self-medicating their anxiety by consuming more alcohol. Targeting the prevention and reduction of withdrawal symptoms of alcohol consumption could be effective in treating alcoholism. 

Further, since adolescents are more vulnerable to developmental neurodegeneration (both in general but also from alcohol consumption) understanding the effects of alcohol on the brain in relation to anxiety could prevent impairments in functional brain activity and cognitive dysregulation.[17] This could benefit adolescents for the rest of their lives, as neurological changes from alcohol consumption that occur during adolescence have the potential to permanently impair their psychological abilities, thus hindering the ability to achieve their goals. 

If you or a friend/family member suspect you may have alcohol addiction, please reach out to a licensed mental health provider to discuss treatment options. 

Contributed by: Preeti Kota

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

REFERENCES

1 Schuckit, M. & Hesselbrock, V. (1994). Alcohol dependence and Anxiety Disorders: What is the Relationship? The American Journal of Psychiatry, 151(12), 1723-1734. 

2 Ibid.

3 Gilpin, N., Herman, M., & Roberto, M. (2015). The Central Amygdala as an Integrative Hub for Anxiety and Alcohol Use Disorders. Biological Psychiatry, 77(10): 859-869. https://doi.org/10.1016/j.biopsych.2014.09.008

4 Witt, E. (2010). Research on alcohol and adolescent brain development: opportunities and future directions. Alcohol, 44(1): 119-124. https://doi.org/10.1016/j.alcohol.2009.08.011

5 Ibid.

6 Gilpin et al. (2015)

7 Ibid.

8 Ibid.

9 Silberman, Y. (2009). Neurobiological mechanisms contributing to alcohol-stress-anxiety interactions. Alcohol, 43, 509-519. doi: 10.1016/j.alcohol.2009.01.002

10 Gray, T., & Bingaman, E. (1996). The amygdala: corticotropin-releasing factor, steroids, and stress. Critical Reviews in Neurobiology, 10(2):155-68. DOI: 10.1615/critrevneurobiol.v10.i2.10

11 Silberman (2009)

12 Ibid.

13 Gilpin et al. (2015)

14 Silberman (2009)

15 Gilpin et al. (2015)

16 Gilpin, N., Karanikas, C., & Richardson, H. (2012). Adolescent Binge Drinking Leads to Changes in Alcohol Drinking, Anxiety, and Amygdalar Corticotropin Releasing Factor Cells in Adulthood in Male Rats. PLoS ONE, 7(2): e31466. doi:10.1371/journal.pone.0031466

17 Zeigler, D., Wang, C., Yoast, R., Dickinson, B., McCaffree, M., Robinowitz, C., & Sterling, M. (2005). The neurocognitive effects of alcohol on adolescents and college students. Preventive Medicine, 40(1), 23-32. https://doi.org/10.1016/j.ypmed.2004.04.044