Understanding the Effects of Temporary Parent-Child Separation

The Commonality of Temporary Parent-Child Separation

Many children around the world experience a temporary separation from a parent for a variety of reasons. The United Nations estimates that 232 million people live and work outside of their native countries; as a result, their children experience temporary separations from one or more parents.[1] Children may also experience temporary absences from their parents due to a parent being deployed in the military; in the United States 1.2 million children have a parent on active duty and 730,000 have a parent on reserve military status. An additional 1.7 million U.S. children experience a separation from a parent due to incarceration.[2] Since children depend on their parents to successfully navigate stressful and traumatic events, parental separation can at times be considered a toxic stressor.[3]

Overall effects

As with any early life stress, parental separation takes a physical and psychological toll. Experiencing extreme stressors at a young age put children at risk for anxiety, depression, post-traumatic stress disorder (PTSD), lower IQ, obesity, decreased immune system functioning, cancer, heart and lung disease, stroke and morbidity.[4] Younger children are shown to be more likely to experience maladaptation immediately following separation and have diminishing problems over time.[5] However, the effects of parental separation can follow a child into adulthood, including increased risk for mental health problems, poor social functioning, insecure attachment and disrupted stress reactivity.[6] Additionally, stressors during adolescence can have lasting effects that do not become evident until adulthood.[7] 

Stages of childhood development also play a role in the effects of temporary separation as children left behind in the ages of 5-8 may experience delayed cognitive development. Further, adolescents that have been left behind/separated from their parent are more likely to take on greater responsibility for the family and perform more routine household tasks, increasing the adolescent’s vulnerability and potentially leading them to risky behaviors (e.g., alcohol consumption, smoking).[8]

The role of gender 

Multiple studies have revealed that the gender of both the child and the parent can play a role in the subsequent effects of temporary parent-child separation. In regards to temporary migrations, Antman’s research (2012) found that daughters who had their father migrate from Mexico to the United States when they were young were tied to higher educational attainment.[9] Antman’s findings tie with previous research that has found paternal migration is not always a stress factor for children left behind and can in times be tied with favorable well-being outcomes due to the changing social status experienced.[10] A study by Mazzucato et al. (2011), found that the effects of a migrating mother are more complex. While families tend to experience economic gain when the father or mother migrate for work,[11] Parrenas (2005) notes that the absence of a mother can lead to increased emotional problems in children (due to the disruption in traditional gender norms regarding child care).[12] 

Effects of the different kinds of separations 

Different kinds of temporary separation bring about their own complex effects on the children left behind. 

• Incarceration: Children of incarcerated parents have greater odds of antisocial behavior in their youth, which may be tied to the stigma attached to incarceration making it more difficult for youth to search and find social support.[13] 

• Migration: Individual studies on the effects of parental migration have reported youth have higher risk of diminished happiness, academic performance and social support seeking along with increased depressive symptoms.[14] The Society for Research in Child Development reports there is an increased mental health risk for both parents and children when they are separated in the immigration process. The Society furthers that native United States children who witness a parent’s border detention or deportation are at an increased risk of developing mental health problems (e.g., anxiety, depression, behavior problems, symptoms of PTSD).[15]

• Military Deployment: Rodriguez et al. (2015) note that meta-analyses have shown statistically significant small increases over time in children’s mental health problems, behavior problems and school problems linked to parental military deployments.[16] Different kinds of deployments can also have different degrees of effects. Rodriguez et al. add that wartime deployments and deployments to an area directly involved in war are linked with increased distress and mental health problems among family members.[17] However, youth and parental ratings of family functioning are shown to improve with an increasing number of military deployments, most likely due to becoming accustomed with the situation.[18]

Communication is Key

Despite the afore-mentioned negatives, temporary parent-child separations can be an opportunity to foster quality communication between the parent and child, creating resilience in children. The level of communication between parent and child can have great effects on the child’s mental health and overall acclimation to a change in family functioning. Zhou et al. (2021) found that low frequency of parent-child communication put children aged 7-17 at higher risk for developing depressive symptoms; conversely, high frequency of communication was tied with enhanced quality of life for the children left behind/separated.[19] It has also been shown that youth who have contact with their incarcerated parents report less alienation and anger in regards to the incarcerated parent, and are less likely to have school problems.[20] 

Quality communication between the parent and child helps to foster resilience, the ability to recover from stressful experiences quickly and efficiently. Building such resilience is a great skill for any child to have since it can help them overcome the eventual hurdles of life. Other ways caregivers can foster resilience in children include:[21,22]

• Explaining where and why the parent is leaving in advance of the departure 

• Allowing the child to take part in leave-taking rituals (e.g., allowing the child to say goodbye to the parent even if the child is very young)

• Trying to create routine and sticking to it (even when the parent returns)

• Creating a safe environment for the child to speak freely

• Acknowledging and validating the child’s concerns 

• Reassuring the child they are not alone

• Encouraging active play and skill building to teach children problem-solving skills in a fun setting

• Sharing honest and age-appropriate information with the child

After a separation some sadness is completely normal, but if adjustment is not seen after a few weeks, there may be cause for concern. It may be helpful to increase the love, attention, and affection to the child and to encourage them to express their feelings.[23] Since it is common for caregivers to feel overwhelmed with responsibilities, asking other trusted adults for help can improve the situations for both caregiver and child.[24] If you feel like you or your child are experiencing negative emotional or behavioral effects due to a separation, please consider seeking licensed child- or family-counseling for help in navigating the situation. 

Contributed by: Maria Karla Bermudez

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

1 Rodriguez, A. J., & Margolin, G. (2015). Parental incarceration, transnational migration, and military deployment: Family process mechanisms of youth adjustment to temporary parent absence. Clinical Child and Family Psychology Review, 18(1), 24-49. doi:https://doi.org/10.1007/s10567-014-0176-0

2 Ibid. 

3 The science is clear: Separating families has long-term damaging psychological and health consequences for children, families, and Communities. Society for Research in Child Development SRCD. (2018). Retrieved March 10, 2023, from https://www.srcd.org/briefs-fact-sheets/the-science-is-clear 

4 Ibid. 

5 Ibid. 

6 Rodriguez (2015)

7 SRCD (2018)

8 Antia, K., Boucsein, J., Deckert, A., Dambach, P., Račaitė, J., Šurkienė, G., Jaenisch, T., Horstick, O., & Winkler, V. (2020). Effects of International Labour Migration on the Mental Health and Well-Being of Left-Behind Children: A Systematic Literature Review. International Journal of Environmental Research and Public Health, 17(12). https://doi.org/10.3390/ijerph17124335

9 Antman F. M. (2012). Gender, Educational Attainment, and the Impact of Parental Migration on Children Left Behind. Journal of population economics, 25(4), 1187–1214. https://doi.org/10.1007/s00148-012-0423-y

10 Antia et al., (2020)

11  Mazzucato, V., & Schans, D. (2011). Transnational Families and the Well-Being of Children: Conceptual and Methodological Challenges. Journal of marriage and the family, 73(4), 704–712. https://doi.org/10.1111/j.1741-3737.2011.00840.x

12  Parrenas, R. S. (2005). Children of global migration: Transnational families and gendered woes. Stanford, CA: Stanford University Press.

13 Rodriguez (2015)

14 SRCD (2018)

15 Ibid. 

16 Rodriguez (2015)

17 Ibid. 

18 Ibid. 

19 Zhou, C., Lv, Q., Yang, N., & Wang, F. (2021). Left-Behind Children, Parent-Child Communication and Psychological Resilience: A Structural Equation Modeling Analysis. International journal of environmental research and public health, 18(10), 5123. https://doi.org/10.3390/ijerph18105123

20 Rodriguez (2015)

21 Church, C. (n.d.). Helping children through a parent's deployment. SMART Couples - University of Florida, Institute of Food and Agricultural Sciences - UF/IFAS. Retrieved March 12, 2023, from https://smartcouples.ifas.ufl.edu/married/military-couples-corner-/helping-children-through-a-parents-deployment/ 

22 Martoma, R. (2020, July 1). Tips to support children when a parent is in prison. HealthyChildren.org. Retrieved March 12, 2023, from https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/Tips-to-Support-Children-When-a-Parent-is-in-Prison.aspx 

23 Church (n.d.)

24 Martoma (2020)

When Dreams Overpower Reality: Maladaptive Daydreaming

Maladaptive Daydreaming - What’s the Harm?

Daydreams can be a regular part of daily life—fleeting flights of fancy that come and go, often lasting no more than a few minutes at a time. However, sometimes daydreams can begin to get out of hand. They can stretch out for hours at a time, and become so detailed and realistic that a person feels intense, authentic emotions in response to them.[1] These daydreams can become  so overly involved that they bring the person to unconsciously speak or act out things that are occurring in their daydreams, and start to absorb more of a person’s attention and time than their real lives do.[2] At face value, maladaptive daydreaming may seem harmless. It’s easy to dismiss it as simply an “overactive imagination,” to expect the individual to simply control their wandering mind, and to undercut the potential consequences it carries. If daydreaming is common and natural - when does it become maladaptive?

The short, simple answer is that daydreams begin to become maladaptive when they begin to have a strong, negative impact on a person’s daily life. Poerio (2023) explains that those who experience maladaptive daydreaming cannot just turn off their daydreams, or shift their focus; the need to actively engage in, and be consumed by, their daydreams is a compulsion. As such, the act of daydreaming can overpower multiple facets of their day-to-day life. These individuals will, often entirely unintentionally, prioritize their daydreams over commitments to things such as school or work; they will let coursework, tests, and projects go undone in favor of focusing on their fantasies.[3] A study performed by Jayne Bigelsen and her colleagues (2015) reported that some maladaptive daydreamers spend at least half of their waking hours daydreaming and honing the intensely detailed plots they create.[4] 

Similarly, social lives of maladaptive daydreamers can also suffer as a result of this condition. They will fail to respond to their friends, be present in relationships or go on outings purely because they are so focused on their daydreams, which can take up several consecutive hours of their day.[5] The effect that maladaptive daydreaming has on an individual’s life is so great that, Soffer-Dudek (2022) concluded in a study that nearly half of the sample of maladaptive daydreamers were unemployed, and more than a fourth had attempted suicide at least once in their life.[6]

WHAT CAUSES MALADAPTIVE DAYDREAMING?

While one, definitive cause of maladaptive daydreaming has not been discovered, multiple factors may influence whether or not a person will develop this disorder. Some theories suggest that maladaptive daydreaming is a coping mechanism. If an individual’s life or experiences are intensely traumatic, they can develop the capability to create a different, safer, more preferable world to escape into—only to have that coping strategy get out of hand and become a dominant fixture in their life.[7] The appeal of their daydreams lies in just how rewarding they are compared to their daily lives. However, many without traumatic histories experience maladaptive daydreaming, with some reporting that their daydreams are actually more intense or stressful than their real lives are.[8]

Others point at the link between maladaptive daydreaming and other disorders, namely OCD, depression, and anxiety. Somer and his colleagues (2017) reported that over half of the participants who experienced maladaptive daydreaming also exhibited symptoms of OCD (though it’s not stated whether or not those participants were actually diagnosed with OCD).[9] As such, the same mechanisms in our brains that result in OCD may also influence the development of maladaptive daydreaming. With anxiety and depression, on the other hand, maladaptive daydreaming is viewed more as a reaction to the already existing disorders. Because the daydreams supposedly provide “an escape from intolerable feelings and conflicts, emptiness, stressful external conditions, and/or unresolved trauma,” the presence of depression and anxiety can spur a person into developing maladaptive daydreaming. However, while these daydreams may provide temporary relief, they are not a functional long-term solution; that brief comfort provided via daydreaming leads to feeling even more discomfort when the daydream ends—often driving the individual to daydream even more frequently in an effort to cognitively escape.[10]

At the present time, maladaptive daydreaming is not an officially recognized disorder, and thus, a person can’t technically be “diagnosed” with it. However, a physician or licensed, qualified mental health professional can still assess if a person is engaging in maladaptive daydreaming. One diagnostic tool, the Structured Clinical Interview for maladaptive daydreaming (SCIMD), is a 16-item test that asks an individual questions about their daydream triggers, how they feel while daydreaming, and how their daydreams affect their daily life.[11]

THE DAYDREAMERS’ PERSPECTIVE

Maladaptive daydreams can range from wild, fantastical storylines, to personal renditions of popular media, to stories that seem entirely grounded in reality. One individual might daydream about a world with hyper-advanced space travel, and all that entails.[12] Another might daydream about their own life, with only minor tweaks here and there. Another might daydream about being involved in an existing foreign conflict.[13] 

While maladaptive daydreaming can negatively impact a person’s life in a variety of ways, many people who experience it have a positive relationship with their condition, and would not sacrifice it if given the opportunity.

Lee (2019) describes a Canadian teenager named Maddie. By her own account, Maddie has been maladaptively daydreaming since she was a young child; as a little girl, she often paced in her driveway while daydreaming. She did this often enough and for long enough periods to wear through the grass and leave a strip of exposed dirt in her wake.[14] These vivid, consuming daydreams continued to be regular parts of her day through her teen years; by her estimate, she spends about four hours every single day daydreaming.[15] The time that her daydreams command has affected her schoolwork, social life, and her perception of her own identity, since she feels she knows the Maddie that exists in her daydreams better than the one that exists in real life. The extent of her daydreams even caused her to question her sanity in her early teen years, before learning about the concept of maladaptive daydreaming. But despite the confusion and distress it has caused her, and the impact it has on her outside life, Maddie considers her maladaptive daydreaming to be a part of her, and enjoys many parts of it.[16]

Karina Lopez, another individual who experiences maladaptive daydreaming, shares a similar fondness for her condition. That’s not to say that maladaptive daydreaming doesn’t complicate aspects of her life. Many times in the past, her daydreams have taken priority over necessary tasks, such as grocery shopping or studying for important exams.[17] In her college years, she would spend up to six hours a day daydreaming; she has since brought that number down to three. Much like Maddie, though, regardless of the negative impacts, Karina does (to some degree) love her condition. She enjoys the process of fine-tuning the daydreams, and looks forward to engaging with them, stating, “As soon as I wake up, I want to daydream.”[18]

However, this welcoming perspective isn’t universal. Unlike Maddie and Karina, both of whom report having experienced maladaptive daydreaming since their youth, Carol didn’t begin maladaptive daydreaming until she reached middle adulthood, and believes the daydreams were brought about by the hormonal shift that came with menopause.[19] While Maddie and Karina both view their daydreams as fascinating stories to explore and retreat into, Carol describes her daydreaming as being similar to, “being tied to a chair and forced to watch a film.” She also feels that her maladaptive daydreaming negatively impacts her creativity, since all of her creative energy is being funneled into her daydreams, whether she wants it to be or not.[20]

TREATMENT OPTIONS

Proposed treatment options for maladaptive daydreaming are limited, for two reasons. The first reason is maladaptive daydreaming is still a relatively new term and concept, having only been coined by Dr. Eli Somer in 2002.[21] Therefore, in the grand scheme, there has been limited time to research the condition or test the effectiveness of varying treatment options. Secondly, while maladaptive daydreaming is gaining more recognition among the medical and mental health communities, it is not yet recognized in the DSM-5 as a psychological disorder at this point in time.

Currently, the most recommended form of treatment for maladaptive daydreaming is cognitive behavioral therapy (CBT).[22] The goal of treatment with CBT is to help the individual understand why they have developed the tendency to daydream to such an excessive extent, and how best to manage their symptoms and ground themselves in reality.[23] Because of its believed link to conditions like anxiety, OCD and depression, therapies and treatment methods employed for those disorders may also be beneficial for those experiencing maladaptive daydreaming.[24]

If you think you may be experiencing maladaptive daydreaming, 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 Jay, S. (2023). Maladaptive Daydreaming. Sleep Foundation.

https://www.sleepfoundation.org/mental-health/maladaptive-daydreaming

2 Ibid.

3 Poerio, G. (2023). When too much daydreaming becomes a disorder. CNN.

https://www.cnn.com/2023/01/09/health/maladaptive-daydreaming-disorder-wellness-partner/index.html

4 Ibid.

5 Ibid.

6 Soffer-Dudek, N. (2022). Why We Should Take “Maladaptive Daydreaming” Seriously. 

Psychology Today. 

https://www.psychologytoday.com/us/blog/consciousness-and-psychopathology/202205/why-we-should-take-maladaptive-daydreaming-seriously

7 Poerio (2023)

8 Robson, D. (2022). ‘I just go into my head and enjoy it’: the people who can’t stop 

daydreaming. The Guardian. 

https://www.theguardian.com/science/2022/aug/28/i-just-go-into-my-head-and-enjoy-it-the-people-who-cant-stop-daydreaming

9 Poerio (2023)

10 Laderer, A. (2022). Here’s What Maladaptive Daydreaming Really Feels Like. Wonder Mind. https://www.wondermind.com/article/maladaptive-daydreaming/

11 Cirino, E. (2021). Maladaptive Daydreaming. Health Line.

https://www.healthline.com/health/mental-health/maladaptive-daydreaming

12 Robson (2022)

13 Lee, J. (2019). Maladaptive Daydreaming — How this psychiatric condition can impact creativity. We Present. https://wepresent.wetransfer.com/stories/maladaptive-daydreaming

14 Ibid.

15 Ibid.

16 Ibid.

17 Robson (2022)

18 Ibid.

19 Lee (2019)

20 Ibid.

21 Laderer (2022)

22 Cleveland Clinic. (2022). Maladaptive Daydreaming. 

https://my.clevelandclinic.org/health/diseases/23336-maladaptive-daydreaming

23 Ibid. 

24 Laderer (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)

Post-Modernism & Spirituality: A Remedy for Depression

The Epidemic of Depression in the Post-Modern Age

Depression is one of the most common mental illnesses in the US. Among the 21 million adults that are affected by at least one major depressive episode, it is majorly prevalent in individuals aged 18-25, and higher among adult females.[1] Depression is still rising at an alarming rate despite the existence of multi-billion-dollar pharmaceutical companies and growing healthcare industry, as not everyone has access to care nor can afford it. Some of the signs and symptoms of depression include, but are not limited to:[2]

• Persistent sad, anxious, or “empty” mood

• Feelings of hopelessness, or pessimism

• Feelings of irritability, frustration, or restlessness 

• Feelings of guilt, worthlessness, or helplessness

• Loss of interest or pleasure in hobbies and activities

• Decreased energy, fatigue, or feeling "slowed down"

• Difficulty concentrating, remembering, or making decisions

• Difficulty sleeping, early morning awakening, or oversleeping

• Changes in appetite or unplanned weight changes

Hidaka (2012) notes that, using a retrospective methodology, modernity is a cause of the current predicament [2]. That is to say, the equivalent progress of physical well-being in mental health is lacking. For example, significant lifestyle changes have occurred over the past century due to technological advancements and urbanization, resulting in a decrease in individuals' physical activity.[3] Similarly, technological facilities like social media can become problematic wherein they contribute to psychological distress – manifesting as depression and anxiety – of adolescents and young adults by impairing their personal and social development.[4]

Daniel Goleman, who has written extensively on mindfulness, emotional intelligence, and depression, identified the consequences of modernity in 1992 as a cause for rising depression. He reported that the rise in divorce rates, loss of nuclear families, and increasing industrialization (which often results in parents spending less time with their children) prepared a breeding ground for a lack of self-identification, hopelessness, and social support for young adolescents as well as elderly people.[5]

Spiritually Integrated Psychotherapy

Treating depression with modern therapeutic measures (such as Cognitive Behavioral Therapy (CBT) and SSRIs) has been largely successful; one way to improve outcome efficacy may be to include Spiritually Integrated Psychotherapy (SIP). One difficulty with this implementation, however, is noted by Harris & Goldberg: modernity is, unfortunately, characterized by a conflict between religion and the secular world.[6,7]

Despite this characterization, a study by Pew Research in 2010 found that nearly 84% of the world’s 6.9 billion people still identified as religious.[8] As Rosmarin et al. noted, individuals facing mental health distress are showing a growing interest in practices that involve spirituality/religion.[9] As the religious needs of the population increase, the 21st century is seeing a rise in the integration of the mind, body, and spirit in the psychological field. Luchetti et al. (2021) identified a new interest rising among clinical mental health practices: integrating spirituality/religion into therapeutic measures;[10] as a result, SIP has become one of the major fields in psychology.[11]

To shed light on SIP, an understanding of ‘spirituality’ is in order. Defined by author Kenneth Pargament, as “the search for the sacred,”[12] it is not a concrete set of beliefs that are rooted in one religion - rather it is fluid and constantly changing. The word ‘sacred’ might prompt a notion of the individual’s relationship with God or a higher power; however, secular, psychological, physical, and social aspects can also be imbued with the sacred. As defined by Pargament, the ‘sacred’ is a significant object that is responsible for order and coherence in an individual’s life. Additionally, stages in an individual’s life that include discovery, struggle, and transformational coping can all be part of one’s spirituality.[13]

Psychotherapy (i.e., talk therapy) emphasizes building a relationship with the patient to relieve them of their mental strain. Even though this does not guarantee the complete eradication of a mental illness, it is especially helpful for patients to develop better strategies of their own, alleviate stress, and establish a better understanding of their obstacles. SIP builds upon traditional psychotherapy, enhancing it with the added component of spirituality.

Through SIP people can draw from psychological, religious, and spiritual perspectives to create and sustain a meaningful purpose in life. A client may choose to use music, art, poetry, church, ritual, prayer, meditation, and mindfulness to express their spiritual emotions. These methods can be used to examine if a client feels they have a spiritual emptiness and help them discover meaning in difficult life events, catering to any emotional/spiritual struggles.

SIP & Depression

Spirituality can be a coping mechanism when facing physical or psychological adversity, which has made spiritual intervention an important aspect of health care. In the event of physical adversity and in regards to mental health, spirituality-based interventions have shown promising results in the recovery from, and the prevention of, depression.[14] For example, In 2011, Delaney et al. examined patients suffering from cardiovascular diseases who took part in a 1-month intervention program focusing on spirituality. Participants demonstrated an increase in the overall quality of life as well as lower depression scores.[15] Similarly, Saisunantararom et al. (2015) found that patients with chronic kidney disease were better able to manage their depression with an understanding of spirituality.[16] A study by Bamonti et al. (2016) showed depressive older adults with high levels of spirituality reported levels of meaning in life equal to those who did not have depressive symptoms. This suggests that incorporating spirituality fosters a meaning of life, showing a link between the preservation of the meaning of life and spirituality.[17] 

In light of these studies, patients who indicate higher spirituality also indicate higher meaning in life and peace. As a result, most (if not all) types of spiritualities show common themes of a quest for deeper meaning and a kind of transcendence from the material aspect of life, resulting in a deeper sense of meaning. Considering the broad nature of spirituality, it encompasses many elements which can be used independently in psychotherapy based on the needs of the client. These elements help tackle the significant symptoms of depression such as hopelessness, loss of interest, or feelings of worthlessness. Such elements include:[18]

• Self-acceptance - Uncovering and accepting the real you; breaking through barriers

• Forgiveness - Dealing with past trauma and moving forward

• Self-Transcendence - Connecting with nature, others, and the divine

• Gratefulness - Counting your blessings; includes forgiveness of others

• Prayer - Counseling sessions, active listening, or asking for divine help

Spiritually integrated psychotherapy that is well-developed and fluid caters to the varying worldviews of individuals and often helps them gain a comprehensive methodology to overcome the challenges life throws at them. If you are interested in exploring SIP, reach out to a licensed mental health care provider who is versed in this methodology to discuss your options.

Contributed by: Musa Zafar

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

references

1 U.S. Department of Health and Human Services. (2022, January). Major depression. National Institute of Mental Health. Retrieved December 6, 2022, from https://www.nimh.nih.gov/health/statistics/major-depression 

2 Hidaka, B. H. (2012). Depression as a disease of modernity: explanations for increasing prevalence. Journal of affective disorders, 140(3), 205-214.

3 Lambert, K. G. (2006). Rising rates of depression in today's society: consideration of the roles of effort-based rewards and enhanced resilience in day-to-day functioning. Neuroscience & Biobehavioral Reviews, 30(4), 497-510.

4 Greenfield, S. (2015). Mind change: How digital technologies are leaving their mark on our brains. Random House.

5 Goleman, D. (1992, December 8). A rising cost of modernity: Depression. The New York Times. Retrieved December 6, 2022, from https://www.nytimes.com/1992/12/08/science/a-rising-cost-of-modernity-depression.html

6 Harris, S. (2005). The end of faith: Religion, terror, and the future of reason. WW Norton & Company.

7 Goldberg, M. (2006). Kingdom coming: The rise of Christian nationalism. WW Norton.

8 Author. (2022, April 14). The global religious landscape. Pew Research Center's Religion & Public Life Project. Retrieved December 6, 2022, from https://www.pewresearch.org/religion/2012/12/18/global-religious-landscape-exec/ 

9 Rosmarin, D. H., Forester, B. P., Shassian, D. M., Webb, C. A., & Björgvinsson, T. (2015). Interest in spiritually integrated psychotherapy among acute psychiatric patients. Journal of consulting and clinical psychology, 83(6), 1149–1153. https://doi.org/10.1037/ccp0000046

10 Lucchetti, G., Koenig, H. G., & Lucchetti, A. (2021). Spirituality, religiousness, and mental health: A review of the current scientific evidence. World journal of clinical cases, 9(26), 7620–7631. https://doi.org/10.12998/wjcc.v9.i26.7620

11 Smith, L. C. (2007). Conceptualizing Spirituality And Religion: Where We'Ve Come From, Where We Are, And Where We Are Going. Journal of Pastoral Counseling, 42.

12 Derezotes, D. S. (2009). Kenneth I. Pargament: Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred.

13 Ibid.

14 Baetz, M., & Toews, J. (2009). Clinical implications of research on religion, spirituality, and mental health. The Canadian Journal of Psychiatry, 54(5), 292-301.

15 Delaney, C., Barrere, C., & Helming, M. (2011). The influence of a spirituality-based intervention on quality of life, depression, and anxiety in community-dwelling adults with cardiovascular disease: a pilot study. Journal of Holistic Nursing, 29(1), 21-32.

16 Saisunantararom, W., Cheawchanwattana, A., Kanjanabuch, T., Buranapatana, M., & Chanthapasa, K. (2015). Associations among spirituality, health-related quality of life, and depression in pre-dialysis chronic kidney disease patients: An exploratory analysis in thai buddhist patients. Religions, 6(4), 1249-1262.

17 Bamonti, P., Lombardi, S., Duberstein, P. R., King, D. A., & Van Orden, K. A. (2016). Spirituality attenuates the association between depression symptom severity and meaning in life. Aging & mental health, 20(5), 494-499.

18 Pečečnik, T. M., & Gostečnik, C. (2022). Use of Spirituality in the Treatment of Depression: Systematic Literature Review. Psychiatric Quarterly, 1-15.

Back to School: How Students and Parents Can Cope with Anxiety in the Wake of the Uvalde Tragedy

In the Wake of Uvalde

The nation was shaken following the traumatic Uvalde school shootings on May 29, 2022, resulting in the fatality of 19 students and 2 adults.[1] Parents, students, and teachers listened in shock to the reports of a joyous day of honor roll celebrations ending in such startling tragedy.[2] Annual preparations for a relaxing summer slowed to a halt as the country took time to mourn.

In the days that followed, parents across the nation chose not to send their children to school.[3-5] This abrupt transition to summer now leaves some parents wondering how to reconcile these events and approach the coming school year. Even though most students and parents were not in physical proximity to this crisis, evidence shows that repeated exposure to school shootings on the news is having an impact on mental health.

It's important to recognize that these events are not occurring in isolation but are instead following a series of national struggles including the COVID-19 pandemic, devastating wildfires, destructive hurricanes, economic uncertainty, and equal rights protests.[6] Roxane Cohen Silver, PhD describes these experiences as “a cascade of collective trauma,” in which, “our reserves are depleted as a nation, and our young people are suffering.”[7]

In an interview with US News, the director of the Child and Adolescent Mood Disorders Program at UCLA’s Semel Institute explained that the increase in violence at schools is impacting all children, saying, “You don’t have to be where the acute distress occurred to get acute stress reactions or PTSD… Nationally, kids are asking more and more if it’s safe to go to school.”[8] Repeated exposure to these events on the news has been increasing in recent years. Education Week’s most recent report states that as of July, there have already been 27 school shootings resulting in 83 people either killed or injured in 2022.[9] Additionally, over 900 school shootings have taken place since the tragedy at Sandy Hook Elementary almost ten years ago.[10]

As these events become more common, they can chip away at the sense of safety and security that would normally be expected in a school environment. Even those who are indirectly exposed to a traumatic event, through hours of media exposure, can contribute to the development of PTSD-like symptoms.[11] In a 2018 survey conducted on “Generation Z,” (the generation born between 1997-2012 that is most directly impacted by the rise in these events) 72% of students surveyed stated that they considered school shootings to be a significant source of stress.[12] Adding to the devastation is the sense of loss and confusion at the end of an event. Since these shootings often result in the suicide of the shooter, the public is left without answers as to the motivation of the violence or what could have been done to prevent it, which can have long-term psychological impact even to those who do not directly experience it.[13] The persistent exposure to these topics in the media can lead to a cycle called, “perseverative cognition,” in which exposure to violence in the media causes distress, leading an individual to worry about future violence, which causes the individual to consume more media.[14]

The impact school shootings have on children throughout the nation can be found dating as far back as the Columbine tragedy in 1999; when a sample of high school students who were not directly involved with the event indicated a 30% increase that they “did not feel safe returning to school” and absences of students due to safety concerns were 2.6 times higher in the days that followed the tragedy.[15] This statistic is backed by a 2014 analysis of Twitter accounts following the 2012 Sandy Hook Elementary tragedy in Newton, Connecticut, which showed that while distance and time from the physical event may have decreased the use of words related to sadness, the use of words related to anxiety actually increased.[16] This increase in anxiety may be due to a phenomenon called, “psychological proximity,” which can cause people to become more severely impacted by an event if they are able to identify with the victims.[17]

Increased access to instant news and updates through social media is broadening the impact these events have on a national level.  In the week following the Sandy Hook Elementary shooting in 2012, three million tweets circled the globe with some providing instant access to graphic images of the scene.[18] Recent decades have drastically changed our access to information, with the emergence of devices that allow people to simultaneously receive and stream information about tragic events twenty-four hours per day.[19] This was illustrated when teenagers caught  in the middle of the Stoneman Douglas High School shooting used their personal smartphones to live stream and tweet their own experiences.[20] These events illustrate how the public is increasingly gaining access to details in near real time, which can simulate personally experiencing the tragedy.  

All of this raises the question of how to move forward. In the wake of yet another school tragedy, how can students and parents address the fear that arises from beginning another school year?

Preparing Students to Return

While the initial instinct may be to shelter children from school tragedies, current evidence indicates that children are able to better process the news when it comes from parents than when they learn about it through peers or social media.[21] Parents need to approach the topic of returning to school differently with children depending on their age. Kary Kunzelman, who supervises a mental health outpatient program in Butler County, Ohio, called Community First Solutions, warns that parents should monitor how they are reacting to the news of events because even if parents believe they are shielding children by not discussing the news, children can often tell that something is wrong and that their parents are behaving differently.[22] 

For younger children, parents can start the discussion by asking them how they feel about returning to school and helping them find words that describe their feelings such as sad, angry, or frightened.[23] Experts recommend discussing these topics, in a simple factual manner, because it is important for them to see that there is language that can be used to describe these feelings.[24]

Children should be reassured that adults in their lives have plans in place to keep them safe.[25] They will trust adults more if they provide truthful answers, so it’s important to state that even though schools are generally safe places, there are still risks.[26] Parents can review with their children the plans that are in place at school if a dangerous situation develops and allow children to explain what they would do.[27] This is not only an opportunity to review safety procedures but can also empower students by helping them understand that they have some control in the situation.

With younger children, it’s also important to limit exposure to the news when new events occur since they may lack the skills to process events in the way they were intended to be perceived. For example, in the days following September 11, 2001, children watching the events unfold on television interpreted the replayed footage to mean that hundreds of planes were repeatedly flying into buildings.[28] If elementary school children want to see images of an event to know and understand what is going on, parents can choose photos that focus on positive contributions, such as showing relief efforts aimed at helping the families.[29] This will provide reassurance that there are people helping in bad situations and that things can be done to make a situation better.

Tweens and young teens are likely already familiar with recent tragic events and have heard various versions from friends and social media. Start by checking in with them about their feelings towards returning to school. It’s best to hear what they have to say and discuss any concerns they have while being careful not to interrupt and respectfully correcting misunderstandings.[30] At this age, if students are concerned, they can look for ways to get involved that would be age appropriate.[31] Based on their interests, they can volunteer in the community or work with school clubs to find solutions for concerns they have about the school environment.

With teenagers who are aware of these events and are learning about them on social media, it is alright for caregivers to share feelings about the situation, while also modeling positive ways to cope with these feelings.[32] Natalie Lareos, a teenager in South Los Angeles told the press that whenever she enters the classroom, or any public place, she now looks for a place to hide.[33] Teens are reaching the age where they are trying to solve their own problems, and adults in their lives can help them find proactive ways for them to advocate for solutions. Parents can speak with teenagers about what solutions they think would help to solve the problem and search together to find organizations that are advocating for that approach.[34] By volunteering, donating, and learning about solutions, teens focus their energy on advocacy - which is a mature coping mechanism to help address their concerns.[35]

Another common reaction for children of all ages is having no reaction. While some children may want to discuss these events, others may take a while to process their thoughts and will not exhibit reactions until much later.[36] Children who were not initially affected by this tragedy may now express new concern about returning to the school building in the fall. In this case, make sure they know a parent or guardian is available to talk or answer questions if they want to discuss it later.[37] A 2020-2021 analysis (utilizing survey data from 2015 and 2016) of 2,263 teenagers showed that concern about school shootings was correlated with “heightened odds of meeting borderline/clinical criteria for generalized anxiety disorder and panic disorder six months later,”[38] illustrating how the impact may be extended over longer periods of time.

If a child has a history of anxiety or trauma, parents should monitor the child for signs of difficulty coping such as physical complaints, changes in behavior, or difficulty sleeping, to see if professional services may be needed.[39] Even if a child does not have a history of trauma or anxiety, exposure to a singular traumatic event can have lasting consequences. Professionals trained to work with youth can use specialized techniques, like play therapy, which can help children who may not be able to form words to explain what they are feeling.[40] If parents or guardians believe their children are struggling to process their feelings, it is best to seek out professional assistance to determine if counseling or other services may be needed.

There is no easy solution to the issue of gun violence in schools. While parents debate their comfort levels of sending their children back into a school environment, it is worth remembering the need to provide consistency. Unpredictable situations can cause fear for children, so it is important for parents to try to keep their routines as normal as possible, whether in a home or school environment, so that they can experience the comfort of normalcy that can be found through consistency.[41]

Helping Parents Cope with Fear

Prior to Uvalde, in 2018, reports already showed that parental concern over school shootings had reached a two-decade high. In the same year, 54% of parents surveyed reported that additional funding to increase school safety was a top priority, and 44% reported they were “very worried” about an active shooter.[42] With the recent events at the end of the last school year, these fears have only increased. The morning after the Uvalde tragedy, parents throughout the country grappled with the decision of whether to send their children to school. Stories filled the media from places like Encino, where the mother of two elementary school boys chose to keep them home that day, while another mother in Long Beach dropped off her first grader at school and then went to her car and cried.[43] Now, as a new school year approaches, parents find themselves struggling with the decision to either send their children back to the school environment, or return to the homeschool option that many families grew accustomed to during the pandemic.[44] Interest in homeschooling has grown so much this summer that the Deputy Director of the Texas Homeschool Coalition, Jeremy Newman, told NBC News that a June convention showcasing their program was “packed to the brim this year,” and explained that school shootings have historically led to a rise in inquiries.[45]

Yet parents may find themselves questioning this instinctive desire to switch back to a home environment when they hear multiple reports from experts warning of the damaging mental health impacts that missing in-person education has had on youth. On December 7, 2021, the US Surgeon General issued an advisory warning that the youth’s mental health crisis is growing due to the COVID-19 pandemic.[46] This statement is supported by a global study of 80,000 children which found that symptoms of depression and anxiety doubled during the pandemic, and attributes part of these impacts to the months of missed in-person education, as well as missing significant events such as first days of school or graduation ceremonies.[47] Similarly, a recent CDC survey found that high school students who reported having a close relationship with someone at school during the pandemic had “significantly lower prevalence of poor mental health,” (28.4% versus 45.2%)[48] Trying to resolve this simultaneous and seemingly contradictory information on both the dangers and benefits of in-person education can leave parents feeling confused as they struggle to determine how to protect both the physical and mental health of their children.

As parents search for the balance between these two choices, more products are emerging on the market to address these fears, such as the production of bulletproof backpacks, which adds more options, and perhaps more confusion, to this already difficult decision. The day after the Uvalde shooting the company Bulletproof Zone reached their highest sales record to date.[49] This purchase trend continued over the summer with Steve Naramore, owner of TuffyPacks, a company which produces bulletproof backpacks and inserts, stating his company has seen an increase in sales of 300 to 500 percent.[50] These products add more options for parents to consider while navigating the complex choices of the coming school year as they are often still working through processing their own fears.

While navigating this complex barrage of decisions, parents should be careful to monitor their own levels of anxiety and mental health.[51] If someone finds themselves obsessively thinking about potential school threats, and it is beginning to manifest in ways that are unhealthy, the first step is to limit any exposure to news or social media sources that may be drawing their attention back to the topic and repeatedly reminding them of their fears.[52] It’s important for parents to question sources of information and try to evaluate whether this information is helping them move forward and make important decisions or holding them back and reminding them of why they are afraid.

Parents need to make time to process their own feelings and fears that arise from these situations. Monitoring thoughts and listening to their bodies can help to become aware of how they are personally responding.[53] Mental health counselor Stephanie Moir recommends experiencing these emotions, but warns about the dangers of getting stuck, advising that listening to music, writing about thoughts, or drawing a picture may help to pull a person out of the overthinking phase.[54] Talking to friends and making plans together to work through what is happening in the world is also a productive approach.[55] If a parent is having difficulty and experiencing problematic anxiety and/or depressive symptoms, contacting a mental health professional, such as a psychotherapist, psychologist, or psychiatrist, would also provide additional support.  

School psychologist Kay Streeter advises caregivers to deal with these events using the Five Ks:[56]

1. Keep Talking (Talk as a release and to process your own feelings)

2. Keep Thanking (Appreciate that you are here and there are things in life that are good)

3. Keep Planning (Engaging in planning provides a sense of control and hope)

4. Keep Forgiving (Forgiving allows you to let go of anger and move forward)

5. Keep Breathing (Deep intentional breaths can reduce stress and anxiety)

Parents should take time to process their feelings by using their network of support and avoid making any major life-altering decisions in the immediate days that follow an event.[57] With time, as parents work through their thoughts and talk through situations with their support systems, they will be able to sort through the pros and cons of the coming school year and create a plan that meets the needs of their children and themselves.

Working towards a Solution

One of the debilitating effects of experiencing a traumatic event is the feeling of helplessness and despair that can follow.[58] Strickland (2022) states, “Anxiety is meant to prepare us for action, so channel the worries you are feeling into something proactive you can do.”[59] While the specific solution to school shootings in America is hotly debated, there does not seem to be a disagreement that something needs to change. Parents and older teenagers can use the energy generated from anxiety to work towards solving this problem; getting involved with an organization working to mitigate school shootings in a way that makes sense to them, can be a productive approach. 

Advocating for a solution can help to regain a sense of empowerment and remember that it is possible for things to improve. There are multiple organizations working to address this issue at both the local and national level. Finding a group of others who are like-minded to collaborate with and work towards solutions can provide a sense of empowerment. People often make progress towards recovering from trauma when they feel that they have some ability to fight back and take control.[60]

Contributed by: Theresa Nair

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

* If you or someone you know is experiencing signs of PTSD, click here to access our PTSD Self-Care Tips inforgraphic.

References

1 Strickland M. Idaho capital sun - states newsroom: Parents must be prepared to talk to their kids about school shootings. here are tips on how. Idaho Capital Sun. 2022.

2 Anderson N, Lang MJ, Elwood K, et al. What we know about the victims of the school shooting in Texas. The Washington Post. 2022.

3 Gomez M, Hailey Branson-Potts, Shalby C, Watanabe T. Touched by a tragedy; texas school shooting stirs anxiety, fear in L.A.-area parents. The Los Angeles times. 2022.

4 Chuck E. Bulletproof backpacks, homeschool: With no new gun laws, parents make changes of their own. NBC News. June 12, 2022. Available from: https://www.nbcnews.com/news/us-news/uvalde-shooting-parents-feel-no-safe-place-children-rcna32534. Accessed Jul 15, 2022.

5 Weekman K. Parents are facing the "nightmare" choice to send their kids to school after another mass shooting. BuzzFeed News Web site. https://www.buzzfeednews.com/article/kelseyweekman/uvalde-texas-shooting-parent-reactions-social-media. Updated 2022. Accessed Jul 15, 2022.

6 Silver RC, Holman EA, Garfin DR. Coping with cascading collective traumas in the United States. Nature human behaviour. 2021;5(1):4-6. doi:10.1038/s41562-020-00981-x

7 Abrams Z. Stress of mass shootings causing cascade of collective traumas. https://www.apa.org. 2022. https://www.apa.org/monitor/2022/09/news-mass-shootings-collective-traumas. Accessed Jul 15, 2022.

8 School shootings and their effect on student mental health. Curriculum Review. 2018;58(4):8

9 School shootings this year: How many and where. Education Week. -01-05T18:16:47.67 2022. Available from: https://www.edweek.org/leadership/school-shootings-this-year-how-many-and-where/2022/01. Accessed Jul 11, 2022.

10 Li, Jones & Livingston, Kelly. Teachers face mental health challenges dealing with school shootings. ABC News Web site. https://abcnews.go.com/Politics/teachers-face-mental-health-challenges-school-shootings/story?id=85069493. Updated 2022. Accessed Jul 11, 2022.

11 Silver et al., 2021

12 Ibid.

13 Cimolai, Schmitz, J., & Sood, A. B. (2021). Effects of Mass Shootings on the Mental Health of Children and Adolescents. Current Psychiatry Reports, 23(3), 12–12. https://doi.org/10.1007/s11920-021-01222-2

14 Abrams Z., 2022

15 Cimolai et al., 2021

16 Doré B, Ort L, Braverman O, Ochsner KN. Sadness shifts to anxiety over time and distance from the national tragedy in newtown, connecticut. Psychol Sci. 2015;26(4):363-373. doi: 10.1177/0956797614562218.

17 Abrams Z., 2022

18 Cimolai et al., 2021

19 Silver et al., 2021

20 Cimolai et al., 2021

21 Abrams Z., 2022

22 Denise GC. In wake of mass shootings, health experts warn of mental toll. Knight-Ridder/Tribune Business News. 2022.

23 Pearson C. A guide to talking to your children about mass shootings: National desk. The New York times. 2022.

24 Denise GC., 2022

25 Ibid.

26 Strickland M., 2022

27 Ibid.

28 Ibid.

29 Stout C. Chalkbeat: Gun violence: Resources for students, parents, and teachers. Chalkbeat. 2022.

30 Pearson C., 2022

31 Stout C., 2022

32 Pearson C., 2022

33 Gomez et al., 2022

34 Pearson C., 2022

35 Ibid.

36 Stout C., 2022

37 Pearson C., 2022

38 Riehm KE, Mojtabai R, Adams LB, et al. Adolescents’ concerns about school violence or shootings and association with depressive, anxiety, and panic symptoms. JAMA network open. 2021;4(11):e2132131-e2132131. doi:10.1001/jamanetworkopen.2021.32131

39 Strickland M., 2022

40 Hateli B. The effect of non-directive play therapy on reduction of anxiety disorders in young children. Counselling and Psychotherapy Research. 2021;22(1):140-146. https://onlinelibrary.wiley.com/doi/abs/10.1002/capr.12420. Accessed Jul 19, 2022. doi: 10.1002/capr.12420.

41 Strickland M., 2022

42 Sign of the times: Parents so concerned about school safety they are willing to pay for it themselves: New survey shows kids and parents agree: Anxiety runs high over school shootings with the start of new school year; experts cite need for more safe-school solutions. NASDAQ OMX's News Release Distribution Channel. 2018.

43 Gomez et al., 2022

44 Chuck E., 2022

45 Ibid.

46 U.S. surgeon general issues advisory on youth mental health crisis further exposed by COVID-19 pandemic. HHS.gov Web site. https://www.hhs.gov/about/news/2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-crisis-further-exposed-by-covid-19-pandemic.html. Updated 2021. Accessed July 17, 2022.

47 Protecting Youth Mental Health : the U.S. Surgeon General’s Advisory. [U.S. Department of Health and Human Services]; 2021.

48 Jones SE, Ethier KA, Hertz M, et al. Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021. Morbidity and mortality weekly report Supplement. 2022;71(3):16-21. doi:10.15585/mmwr.su7103a3

49 Picket K. Bulletproof backpack companies see record sales hours after texas school shooting. The Washington Times Web site. https://www.washingtontimes.com/news/2022/may/31/bulletproof-backpack-companies-see-record-sales-ho/. Updated 2022. Accessed Jul 18, 2022.

50 Chuck E., 2022

51 DOnofrio M. Axios: Coping tips for parents and teachers after the uvalde school shooting. Axios. 2022.

52 Strickland M., 2022

53 DOnofrio M., 2022

54 Vazquez L. Managing your mental health through crises. WFTS Web site. https://www.abcactionnews.com/news/region-hillsborough/cascading-tragedies-reinforce-need-to-take-care-of-mental-health. Updated 2022. Accessed Jul 18, 2022 

55 DOnofrio M., 2022

56 Stout C., 2022

57 Ibid.

58 Strickland M., 2022

59 Ibid.

60 Curriculum Review.

Manifestations of Childhood Trauma in Adults

Understanding Trauma

More than 70% of adults have experienced a traumatic event at some point in their lives.[1] Trauma exposure is classified as any event that threatens or causes death, injury, or personal integrity.[2] Such experiences can include: emotional, psychological, physical and/or sexual abuse, natural disasters, war, injuries, or neglect. Further, traumatic events can occur as repeated, long-term experiences or as one single incident.[3]

As discussed by Majer et al., (2010), children are particularly receptive to traumatic experiences due to the heightened plasticity of a developing brain,[4] as well as their reliance on the environment for emotional and cognitive development. A child’s environment directly influences gene expression and brain growth; the stress that one’s environment imposes can help or hinder development.[5] While a normal amount of stress is crucial for the strengthening of important neural connections involved in emotional regulation and response to stress,[6] extreme, frequent, or long-lasting stress, will cause the body to adapt by sending a myriad of chemical and hormonal stress signals throughout the brain, altering its functional components.[7,8] Specifically, the overabundance of the stress hormone cortisol, will weaken bodily functions, including immune function, memory, learning, and emotional regulation.[9] Therefore, if childhood trauma occurs and is not properly addressed, it can lead to cognitive impairment and psychological disorders in adulthood.[10] 

When a child's environment feels unsafe or threatened, there are various ways they will adaptively react in order to maintain a feeling of safety and protection. Such reactions include the development of extreme reactivity to stimulation, heightened sense of vulnerability, and the addition of attachment & neediness behaviors.[11] Additionally, research done by The National Scientific Council on the Developing Child (2005/2014) found that the adjustment of the stress-response system, through the strengthening of neural connections involved in fear and anxiety, causes the child to become stressed at a lower threshold.[12] Further, if a child doesn’t receive the proper emotional support and comfort following a traumatic experience, it can disrupt normal brain development and cause issues with emotional regulation and response to stress in adulthood.[13]

Symptoms of childhood trauma in adults

The intensity and type of traumatic exposure in childhood affects how it will appear in adulthood.[14] Traumatic experiences involving one’s caretaker pose the greatest risk to harming the child’s psychological state and development.[15] Additionally, traumatic experiences that are repetitive are more detrimental than a single episode;[16] as the rate of negative childhood experiences increases, so does the likelihood that the adult will experience symptoms.[17]

As it can be difficult for an adult to disclose childhood trauma,[18] the best indication of its existence is through the expression of conscious and unconscious symptoms. While the effects of childhood trauma manifest differently in everyone, common symptoms include: difficulty controlling emotions, impulsiveness, an increased response to stress, relationship instability, development of mental illnesses, dissociation, avoidance, and heightened anger.[19,20]

Many adults who experienced childhood trauma also suffer from memory and learning deficits.[21] Additionally, some adults are found to have high blood pressure and increased inflammation.[22] Childhood trauma can also lead to interpersonal relationship problems including the creation of a “disorder of hope”, in which new relationships are either idealized or hated.[23] Moreover, Su & Stone (2020) note that if traumatic experiences involve a toxic relationship with a caregiver or trusted adult, those dynamics can also be reenacted in the adult’s life, such as involvement with an abusive partner or becoming abusive themselves.[24]          

Link between childhood trauma and mental health

Traumatic experiences that occur during childhood can cause disruptions in adult psychological function and lead to depression, anxiety, post-traumatic stress disorder (PTSD), and dissociation.[25]

Adverse experiences in early childhood can cause changes to the structural and functional components of the body, including increased sensitivity to stress, increased cortisol, glucocorticoid resistance, and decreased hippocampal volume. All of these changes closely parallel the features present in depression, suggesting traumatic experiences increase the risk of developing depression in adulthood.[26] Consequently, there is a high prevalence of childhood trauma in people with depression. It is also common for anxiety symptoms to develop following a traumatic experience, due to the heightened sensitivity to stress and production of cortisol.[27] Further Berber Çelik Ç, Odacı H (2020), found that childhood trauma can lower self-esteem, indirectly leading to the development of depression and anxiety.[28]

In some cases, typically those involving interpersonal violence or assault, traumatic experiences can lead to post-traumatic stress disorder.[29] PTSD refers to the development of symptoms following a traumatic exposure;[30] these symptoms include the re-experiencing of the traumatic event through nightmares, recollections, intrusive images, or reactions to reminders of the event. It also includes avoiding stimuli related to the traumatic event, increased arousal, and mood and thinking disruptions. To qualify as a diagnosis of PTSD, the duration of these symptoms must transpire for more than one month.[31]      

Dissociation also can occur as a result of a childhood trauma, especially if the experience is life-threatening or imposed by a caretaker. Dissociation is a feeling of disconnect towards psychological constructs, including the body, environment, behavior, and memory.[32] Dependent on where the disconnection is occurring, an absence of emotions, disorientation with surroundings, feelings of separation from the body, problems with self-recognition, or disruptions in hearing can transpire.

Treatment

It is never too late to seek help for trauma that occurred during one’s childhood. Although every treatment will not be effective for everyone, options exist.[33] Exposure therapies such as exposure and response prevention (ERP) and prolonged exposure (PE) are some of the modalities used to treat trauma. Individuals are “exposed” to reminders of the traumatic event, but in a safe and comfortable setting. It is common to develop avoidance and fear for stimuli related to one’s traumatic experience, and exposure therapy gradually decreases those negative reactions.[34] Another treatment for trauma is cognitive-processing therapy (CPT). This type of treatment involves recognizing detrimental thought patterns and behaviors related to the trauma, and implementing healthier beliefs about the self, others, and the world. This process can be done through the use of writing assignments and Socratic questioning.[35] Other possible treatments include eye movement desensitization and reprocessing (EMDR), psychoeducation, and support therapy. 

Image Sources [36,37]

Q&A

SAS’ Psychotherapist, Dr. Brittany Canfield, discusses childhood trauma

1. In your experience, how does childhood trauma typically present itself in adults?

“Based on the literature, there are many physical and psychological manifestations of childhood trauma in adults. What we often see in clinical settings is individuals coming in to treat unmanageable anxiety symptoms, depression, mood dysregulation, attentional issues, and challenges maintaining daily functioning. For many, the catalyst for treatment is suffering from personal relationships or difficulty managing their workload. Childhood trauma also hides within the confines of addiction, both in substance and behavioral as well as within personality disorders. Common symptoms reported when seeking treatment include the following:

• Difficulty falling asleep, staying asleep, or sleep disturbances (i.e. sleepwalking, sleep talking, nightmares, and night terrors).

• Anxiety, panic attacks, social anxiety, and obsessive-compulsive symptoms.

• Depression, suicidal ideation, history of suicidal ideation, plans, and/or attempts, self-harm, and/or mood dysregulation, often including anger.

• Attentional issues such as difficulty focusing, retaining information and/or other issues with recall, increased distractibility, decreased memory, losing time, and/or other symptoms commonly associated with ADHD.

• Physical or somatic symptoms called somatization, include but are not limited to frequent headaches, body aches, gastrointestinal issues, chronic fatigue, decreased immune function, and effects related to chronic stress.

• Other symptoms may include diminished self-esteem and self-worth, poor outlook, compassion fatigue or burnout, codependence, poor boundaries, disturbances in interpersonal relationships, and the need to stay busy.”

2. Are there any ways to prevent childhood trauma from affecting adulthood? If so, what are the most effective ones?

“While there is no single preventive tool, one of the biggest factors mitigating the impact of childhood trauma is resilience. The research highlights the protective qualities that resilience has on childhood trauma, especially when that includes a stable and safe connection with just one adult during childhood. Support has also been shown to mitigate the impact of trauma in the way the individual is able to process the experience and progress toward posttraumatic growth.”

3. What types of treatments are most effective in helping adults who are suffering from childhood trauma?

“Given the differences in how children and adults process trauma, further explained below, bottom-up therapies accessing the part of the brain that was impacted during the trauma have been shown to be the most successful. These therapies include somatic-based or somatic experiencing therapies, EMDR, sensorimotor therapy, and expressive arts. Individuals may also benefit from more traditional talk therapies such as cognitive-behavioral therapy (CBT), mindfulness-based CBT, and dialectical behavior therapy (DBT), the latter focusing on resource-building. Additionally, therapy will focus on building skills that can assist the individual in regulating their nervous system and learning to utilize other mind-body activities such as yoga, meditation, and polyvagal techniques, all of which have been shown in the research to mitigate the effects of trauma.”

4. Are there any differences in how children process traumatic experiences compared to adults?

“This is an excellent question and a very important aspect of the impact of trauma on the brain in human development. In childhood, the prefrontal cortex is still developing and will continue to do so well into the mid-20s. With that being said, we process trauma from the bottom-up, that is, from the base or "bottom" of our brain. Bottom-up processing includes our sensory system, meaning that we experience and store the trauma from our senses, thus somatically. Other parts of our brain impacted by trauma include our limbic system and peripheral nervous system. When we experience trauma as an adult and often when childhood trauma is not a precipitating factor, we do so from our prefrontal cortex, which allows us to process the trauma using higher cortical thinking including cognitive processes such as reasoning, language, and awareness. You may wonder why this is so important? People who experience childhood trauma often do not have the words to describe or process what they experienced, because the part of the brain that is engaged in those processes was not the primary part of the brain in use when the trauma occurred. This makes it difficult for childhood trauma survivors to even acknowledge that the trauma happened let alone impacted them.”

5. Do you have any advice or anything you want to share with someone who may be suffering from childhood trauma?

“There is often fear and shame associated with childhood trauma, which can prevent individuals from seeking help. We often internalize social stigma (self-stigma) of seeking help out of fear of being invalidated, shamed, pathologized, or perceived as "crazy." You do not have to go at this alone, feel ashamed for what you have gone through, or carry the burden of your childhood trauma well into adulthood. If you have a childhood trauma history, it is recommended that you seek the help of a professional, join a support group, educate yourself on childhood trauma and often complex PTSD, and engage in activities that regulate the nervous system.”

If you have experienced childhood trauma and would like to explore possible treatment options, please reach out to a licensed mental healthcare provider who specializes in trauma recovery.

For more information, click here to access an interview with Psychologist Michele Bedard-Gilligan on trauma & recovery.

Additionally, you may click here to access an interview with Psychologist Bethany Brand on trauma & dissociation.

To access our PTSD Self-Care Tips, click here.

Contributed by: Amelia Worley

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

References

1 Benjet, C., Bromet, E., Karam, E. G., Kessler, R. C., McLaughlin, K. A., Ruscio, A. M., Shahly, V., Stein, D. J., Petukhova, M., Hill, E., Alonso, J., Atwoli, L., Bunting, B., Bruffaerts, R., Caldas-de-Almeida, J. M., de Girolamo, G., Florescu, S., Gureje, O., Huang, Y., Lepine, J. P., … Koenen, K. C. (2016). The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium. Psychological medicine, 46(2), 327–343. https://doi.org/10.1017/S0033291715001981 

2 Bedard-Gilligan, M., & Worley, A. (2022, May 13). Psychologist Michele Bedard-Gilligan on Trauma & Recovery - Psychology and Psychiatry Interview Series. Seattle Anxiety Specialists, PLLC: Psychiatry & Psychology. Retrieved May 17, 2022, from https://seattleanxiety.com/psychology-psychiatry-interview-series/2022/5/5/q6oxgila8beysefwg0qvb7gve9pb46

3 Harms, L. (2015). Understanding trauma and resilience. Macmillan Education. 

4 Majer, M., Nater, U.M., Lin, JM.S. et al. Association of childhood trauma with cognitive function in healthy adults: a pilot study. BMC Neurol 10, 61 (2010). https://doi.org/10.1186/1471-2377-10-61 

5 Stien, P., & Kendall, J.C. (2004). Psychological Trauma and the Developing Brain: Neurologically Based Interventions for Troubled Children (1st ed.). Routledge. https://doi.org/10.4324/9781315808888 

6 Ibid.

7 National Scientific Council on the Developing Child. (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper 3. Updated Edition. http://www.developingchild.harvard.edu

8 Stien, P., & Kendall, J.C. (2004)

9 Excessive Stress Disrupts the Architecture of the Developing Brain. (2005/2014)

10 Majer, M., Nater, U.M., Lin, JM.S. et al. Association of childhood trauma with cognitive function in healthy adults: a pilot study. BMC Neurol 10, 61 (2010). https://doi.org/10.1186/1471-2377-10-61 

11 Van der Kolk, B. (2003). Psychological Trauma. American Psychiatric Pub. 

12 Excessive Stress Disrupts the Architecture of the Developing Brain. (2005/2014)

13 Stien, P., & Kendall, J.C. (2004)

14 Van der Kolk, B. (2003).

15 Everett, B., & Gallop, R. (2001). The link between childhood trauma and mental illness effective interventions for mental health professionals. SAGE. 

16 Su, W.-M., & Stone , L. (2020, July). Adult survivors of childhood trauma. Australian Journal of General Practice. Retrieved May 16, 2022, from https://www1.racgp.org.au/ajgp/2020/july/adult-survivors-of-childhood-trauma

17 Ibid.

18 Ibid.

19 Ibid.

20 Thatcher, T. (2018, November 20). Healing childhood trauma in adults. Highland Springs Clinic. Retrieved May 8, 2022, from https://highlandspringsclinic.org/blog/healing-childhood-trauma-adults/  

21 Stress disrupts the architecture of the developing brain. (2005)

22 Ibid.

23 Van der Kolk, B. (2003).

24 Su, W.-M., & Stone , L. (2020, July). 

25 Van der Kolk, B. (2003).

26 Christine Heim, D. Jeffrey Newport, Tanja Mletzko, Andrew H. Miller, Charles B. Nemeroff, The link between childhood trauma and depression: Insights from HPA axis studies in humans, Psychoneuroendocrinology, Volume 33, Issue 6, (2008), Pages 693-710, ISSN 0306-4530, https://doi.org/10.1016/j.psyneuen.2008.03.008.

27 Robert S Pynoos, Alan M Steinberg, John C Piacentini, A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders, (1999), Pages 1542-1554, ISSN 0006-3223, https://doi.org/10.1016/S0006-3223(99)00262-0.

28 Berber Çelik Ç, Odacı H. Does child abuse have an impact on self-esteem, depression, anxiety and stress conditions of individuals? International Journal of Social Psychiatry. (2020)171-178. doi:10.1177/0020764019894618

29 Bedard-Gilligan, M., & Worley, A. (2022, May 13)

30 Ibid.

31 Wilson, J. P., & Keane, T. M. (2006). Assessing psychological trauma and Ptsd. The Guilford Press. 

32 Brand, B., & Worley, A. (2022, May 9). Psychologist Bethany Brand on Trauma & Dissociation- Psychology and Psychiatry Interview Series. Seattle Anxiety Specialists, PLLC: Psychiatry & Psychology.

33 Bedard-Gilligan, M., & Worley, A. (2022, May 13)

34 American Psychological Association. (2017, July). What is exposure therapy? American Psychological Association. Retrieved May 10, 2022, from https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy  

35 American Psychological Association. (2017, July). Cognitive processing therapy (CPT). American Psychological Association. Retrieved May 9, 2022, from https://www.apa.org/ptsd-guideline/treatments/cognitive-processing-therapy

36 Bowman, J. (2017, February 9). Socratic questions revisited [infographic] · James Bowman. James Bowman. Retrieved May 17, 2022, from http://www.jamesbowman.me/post/socratic-questions-revisited/  

37 R. W. Paul, L. Elder: The Thinkers Guide to The Art of Socratic Questioning, 2007

Racial Trauma: Experiences and Implications for Therapeutic Settings

Mental Health Disparities 

Persistent and serious health disparities exist in the United States. Minorities suffer poorer health outcomes when compared to the majority, their White counterparts.[1] While there is conflicting evidence in the literature as to whether minorities suffer greater mental health consequences, a general consensus is that they report more psychological symptoms. Even without official diagnoses, minorities present with more subthreshold symptoms, which may reflect the poorer functioning reported within these marginalized groups.[2] 

When it comes to disparities in mental health care, the results are transparent. Numerous studies have found that individuals from minority groups, such as African Americans and Latinx, are less likely to receive treatment.[3] Even when they do receive it, they are less likely than Whites to receive the best care.[4] African Americans are also more likely to terminate treatment prematurely.[5] The most common reasons cited for dropout are not believing the treatment will work, not believing their problems are severe, and not being able to afford treatment.[6]

Racial trauma

Racial trauma (also called race-based traumatic stress) is defined as “the mental and emotional injury caused by encounters with racial bias and ethnic discrimination, racism, and hate crimes.”[7] In the United States, BIPOC (Black, Indigenous, People of Color) individuals are at a heightened risk of experiencing this trauma. Research has shown that race-based discrimination has a profound and detrimental psychological impact. It has even been reported to result in PTSD (post-traumatic stress disorder) symptoms.[8] 

Racial trauma comes in many different forms: microagressions, racism, discrimination (e.g., in the workplace), and police violence/brutality. Each of these will be defined and elaborated on further in the sections below. 

Racial trauma can be a direct experience of racism towards someone or transmitted intergenerationally (from generation to generation). The latter is referred to as generational trauma, which the American Psychological Association (APA) defines as “a phenomenon in which the descendants of a person who has experienced a terrifying event show adverse emotional and behavioral reactions to the event that are similar to those of the person himself or herself.”[9] Although most intergenerational trauma work has been done on Japanese individuals whose ancestors were forced into internment camps during World War II and ancestors of Holocaust survivors, a growing body of research is focusing on current generations of African-Americans and the ongoing discrimination they face.[10] Dr. Monicca WIlliams from the University of Connecticut has extensively focused on this issue and formulated a measure to assess anxiety stemming from racial discrimination. Out of 123 African-American students who took this survey in a study conducted by Williams et al. (2018), perceived discrimination correlated with higher rates of “uncontrollable hyperarousal, feelings of alienation, worries about future negative events and perceiving others as dangerous.”[11] Additionally, a meta-analysis by Pascoe and Smart Richman (2009), which consisted of 134 studies with multiracial samples, demonstrated an association between perceived discrimination and heightened stress responses, poorer physical health, and participation in unhealthy behaviors.[12]

Microaggressions

While most people would not consider themselves to be racist (e.g., do not commit hate crimes nor express blatantly racist sentiments), they may still hold racial biases and engage in subtle racially-motivated behaviors.[13] Harvard psychiatrists have characterized these as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward People of Color.”[14] While microaggressions are often less visible than macroaggressions, they can be just as detrimental.

Examples of Microaggressions in Speech:

Can I touch your hair? It looks so exotic.

That's so gay.

You'd be pretty if you lost some weight.

You speak pretty good English, I am surprised. 

You aren’t really American.

Examples of Microaggressions in Action:

A White woman clutching her purse as a Black man walks past her. 

Mistaking a Person of Color as a service/blue-collar worker

Microaggressions are linked to a plethora of negative outcomes, including depression, fatigue, anger, chronic infections, and high blood pressure. Research addressing the relationship between microaggressions and mental health has consistently found that subtle forms of racism have a detrimental impact on the mental health of BIPOC individuals.[15] Participants in numerous studies reported feeling immediate stress after encountering microaggressions.[16] Additionally, the accumulation of such experiences has had a detrimental impact on their well-being.[17]

Results of a study by Nadal et al. (2014), which included 506 participants, found that higher frequencies of racial microaggressions predicted negative mental health outcomes.[18] Higher rates of racial microaggressions were also significantly correlated with depressive symptoms and negative affect. Nadal et al. also investigated whether race influenced the experience of microaggressions. Significant differences were found between White participants and all other minority group participants. Between minority groups, no difference was found, suggesting that Black, Asian, Latinx, and multiracial people experience similar amounts of cumulative microaggressions.[19] However, differences were found in the types of racial microaggressions that racial groups reported: Black and Latinx participants reported more inferiority-related microaggressions; Black participants reported more criminality-related microaggressions; and Asian participants reported more environmental (i.e., disease- and contamination-risk association) and exoticization microaggressions.[20]

In a 2015 study that focused on the psychological impact of microaggressions on Black women, Fay et al. measured their anxiety and depression symptoms. They found that the women who reported higher levels of racial microaggressions also reported greater symptoms of depression and anxiety.[21] Age or level of education caused no significant effects.[22]

In a study consisting of Black participants, Liao et al. (2016) demonstrated that perceived racial microaggression positively correlated with anxiety symptoms. Investigators were particularly interested in the roles of ethnic social-connectedness and intolerance of uncertainty as moderators between microaggressions and anxiety.[23] “Intolerance of uncertainty” has been described as a core feature of Generalized Anxiety Disorder (GAD) and can be defined as the “tendency to react negatively on an emotional, cognitive, and behavioral level to uncertain situations and events.”[24] Individuals with a high intolerance to uncertainty find situations that are “uncertain” catastrophically threatening and upsetting, regardless of the actual probability of a negative event to occur.[25] They also found that social connectedness to one’s ethnic community was a protective factor, while intolerance of uncertainty was an exacerbating factor.[26] The importance of social connectedness to one's community leads to clinical implications: clinicians can implement these findings into treatment plans, thus likely leading to better outcomes for their clients.

Less work has been done on microaggressions experienced by Latinx individuals. In 2020, Choi et al. sought to bridge this gap and conducted a meta-analysis to determine how microaggressions impacted Latinx well-being. They found that Latinx racial microaggressions were linked to behavioral stress, perceived stress, psychological distress, psychological well-being, and symptoms of depression.[27]

Other research has focused on the impact of microaggressions in younger populations, such as children. Children are in a particularly vulnerable developmental period and studies have shown that racism, like other physical environmental toxins and stressors, can adversely impact one’s developmental trajectory in the socioemotional and behavioral domains. For example, a meta-analysis conducted by Berry et al. (2021) found that racism can have a detrimental impact on children as young as preschoolers, particularly through intergenerational avenues.[28] In fact, it can even impact the child in utero. Racial microaggressions can increase maternal stress, which is linked to preterm delivery.[29]

Macroaggressions

Microaggressions (sometimes referred to as aversive racism) and overt racism must both be taken into account. The studies discussed in the following section focus more on overt instances of discrimination: macroaggressions.

More broadly, the APA defines racism as “generally including negative emotional reactions to members of the group, acceptance of negative stereotypes, and discrimination against individuals, with some cases even leading to violence.”[30] It is important to note that racism is also systemically embedded into existing institutions. At the end of this section are examples of both individual and systemic racism. 

Studies with samples of African-American individuals have found that racism is highly correlated with both mental health issues (depression and stress) as well as physical health consequences (cardiovascular disease and obesity).[31,32] A meta-analysis by Paradies et al. (2015) synthesized the health impacts of racism (293 studies) and found that racism was associated with poorer mental health. BIPOC participants reported experiencing depression, stress, emotional distress, anxiety, PTSD, and suicidal thoughts.[33] 

Studies focusing on Latinx, Asian American, and Native American individuals have indicated that perceived discrimination is correlated with mental health problems. Whitbeck et al. (2022) found that perceived discrimination was a powerful indicator of depressive symptoms in a Native American adult sample, with participants who reported experiencing discirmination being two times more likely to report a greater number of depressive symptoms.[34] Another study by Hwang and Goto (2008) found that among its Asian American and Latinx participants, those who perceived discrimination were more likely to exhibit “symptoms of psychological distress, suicidal ideation, state and trait anxiety, and clinical depression.”[35]

Stress due to racism not only elevates blood pressure, but also leads to risky coping mechanisms that further impact physical health, such as drinking and smoking. For example, Cuevas et al. (2014) found that stress (as a result of discrimination) was linked to smoking and other behavioral risk factors for cancer.[36] Racism and discrimination have also been found to impact inflammation and sleep. A study conducted in 2019 by Thames et al. found that exposure to racial and discriminatory acts activates threat-related molecular processes that stimulate inflammation, which makes people more vulnerable to heart and kidney diseases.[37] Another study by Ong and Williams (2019) found that discrimination interferes with sleep quality in middle-aged adults, further increasing the risk for systemic inflammation.[38]

Examples of Individual Racism:

COVID-19 pandemic: approximately 1,500 reported incidents of anti-Asian racism per month (e.g., physical and verbal attacks and anti-Asian discrimination in private businesses).[39]

2018: 38% of Latinx reported being verbally attacked for speaking Spanish (e.g. told to go back to their countries and racial slurs).[40]

Examples of Systemic Racism:

Despite only making up 12% of the United State’s population, Black people make up nearly 33% of the total prison population.[41] 

BIPOC are less likely than Whites to own their homes regardless of level of education, income, location, marital status, and age due to previous and current policies of displacement, exclusion, and segregation.[42]

Rates of suicide in Native American communities are 3.5 times higher than racial and ethnic groups with lowest rates of suicide. Existing barriers to access appropriate mental health resources for this demographic include lack of financial incentives and cultural competence in as well as geographical isolation.[43]

Assari et al. (2017) aimed to investigate if perceived discrimination in adolescence predicted mental health deterioration a decade later.[44] This longitudinal study followed 681 Black participants from age 15 to age 32. Psychological symptoms of anxiety and depression were measured in 1999 (during adolescence) and again at the follow-up in 2012 (in young adulthood). They only found a positive correlation between perceived discrimination at adolescence and negative psychological symptoms later on for Black males, but not Black females.[45] This may be due to the internalization of masculine norms. Another study by Caldwell et al. (2013) found that masculinity moderates the relationship between discrimination and depressive symptoms plus high-risk drinking behaviors.[46] Discrimnation seems to be more harmful for Black men who hold strong masculine attitudes. Men also report higher rates of discirmination compared to Black women so this could also be another factor accounting for the gender differential.[47] 

In another longitudinal study, this time with a sample of 674 Mexican-origin youth, Stein et al. (2019) investigated whether peer discrimination in 5th grade predicted greater depressive and anxiety symptoms in 12th grade. Peer discrimination was defined as “direct biased mistreatment by peers due to race/ethnicity and also indirect experiences (e.g., hearing classmates make jokes about racial groups).”[48] The results showed that peer discrimination in 5th grade did predict greater symptoms of both depression and anxiety in 12th grade, highlighting the long-term negative impact of these experiences across adolescence.[49] 

Regardless of genetic risk, exposure to discrimination plays a significant role in the development of anxiety disorders. A study in 2020 by Cuevas et al. concluded that even after controlling for genetic factors, discrimination continued being a strong risk factor for anxiety and related disorders.[50] Studies like this confirm that discrimination operates like any other environmental stressor, highlighting its impact on psychiatric disorders and overall well-being. 

Police violence and brutality 

With the high-profile deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery, some researchers have focused on the impact of police brutality and violence as environmental stressors. One such study by Alang et al. (2021) examined the relationship between police brutality, depression, and anxiety across races. They found that negative encounters with police were associated with depressed mood and anxiety, with a stronger association among Black and Latinx participants than Whites.[51] A national survey by Graham et al. (2020) that consisted of 1000 respondents measured the extent to which different racial and ethnic groups in America worried about police brutality. The results demonstrated that Black participants were five times more likely than White people to report fear of such violence.[52] Similarly, Latinx respondents were four times more likely than White people to experience the same fear.[53] Even the anticipation of police brutality (no direct encounter, just concern that one might be a victim) was also associated with depression and anxiety.[54] 

Translating these findings to therapeutic settings: racial socialization theory 

Given all the data regarding the relationship between racism and mental health, it is essential to translate the findings above into therapeutic settings. Clinicians must assess and address racial discrimination within therapy sessions. Further, clinicians should be aware of racial microaggressions and their clinical implications on mental health. 

Many evidence-based trauma treatments are not culturally tailored to address racism and intergenerational trauma.[55] Moreover, African-American adolescents are more likely than their peers to experience traumatic racist and discriminatory encounters. Therefore, not only is this marginalized group more likely to experience these stressors, but they also do not receive the adequate treatment for it, further exacerbating the impact of these encounters.

African American youth are disproportionately impacted by trauma. Finkelhor et al. (2013) found that 65% of African American youth report traumatic experiences.[56] However, only 30% of their peers from other racial and ethnic groups reported the same.[57] These rates may be due to the unique race-related stressors that African American communities experience. Over the course of a single year, 38% of African American teens (13-18 y/o) reported an average of six racist encounters.[58] If these experiences and their associated outcomes (poor mental health) are not addressed and treated, they are at an increased risk of developing PTSD.[59] Existing therapies that aim to provide clients with coping mechanisms (e.g., progressive muscle relaxation and diaphragmatic breathing) for traumatic experience lack culturally-specific strategies necessary to treat the racial stressors unique to African American individuals. The absence of this cultural awareness and implementation most likely reflects the tendency for poor engagement and subsequent dropout among African American patients who undergo therapy.[60]

Racial socialization is a process that transmits culture, attitudes, and values to help youth overcome stressors associated with their ethnic minority status.[61] Researchers like Metzger et al. (2021) have incorporated racial encounter coping appraisal and socialization theory into trauma-focused cognitive behavioral therapy (TF-CBT). By incorporating these techniques into the framework of an already existing evidence-based treatment for children and adolescents, racial trauma can be addressed in clinical settings.[62] Additionally, Metzger et al. integrated racial socialization (RS) into TF-CBT to improve outcomes specifically for African American youth since RS has been associated with lower internalizing and externalizing symptoms in children of color, positive parent-child interactions, self-esteem, resilience, lower rates of depression and stress, reduced behavioral problems, stronger racial identity, and better use of coping skills during race-related traumatic experiences.[63] 

There are several components under the RS umbrella. For example, racial pride messages are those that teach African American children about their heritage and culture. These messages promote group unity and combat negative majority opinions.[64] An example of this is talking about important historical figures. Racial barrier messages are about discrimination and racism; they also warn about difficulties in social interactions with majority populations, such as White communities.[65] An example of this RS technique is encouraging and aiding parents in the police violence and brutality talk. This process also takes advantage of the social connectedness protective buffer mentioned under the “Microaggression” section. Incorporating religion into the TF-CBT framework as a source of resilience has also proved to be helpful for many African American families.[66] 

Another important practice under RS is the acknowledgement and appreciation of extended family members, such as grandparents, aunts/uncles, and other non-blood relatives (e.g., pastor, mother’s childhood best friend who is like an aunt). In African American cultures, extended family involvement is common, with other people outside the immediate family network helping with child-rearing.[67] By including them in treatment plans, outcomes can be optimized. In TF-CBT, parents and guardians are actively involved in administration, given that they are responsible for making sure appropriate coping strategies are practiced outside of therapy sessions. 

Emotion regulation 

A 2015 study by Graham et al. found that the relationship between racist experiences and anxiety symptomatology was moderated by emotion regulation in a Black American sample.[68] In other words, better emotion regulation resulted in fewer anxiety symptoms due to racist experiences. Emotional regulation acted as a buffer to the development of anxiety symptoms. Some researchers even label emotional dysregulation as the core of mood and anxiety disorders.[69]

These results have clinical implications, demonstrating the importance of emotion regulation skills. Reducing racist experiences is ideal, but difficult to tackle. Systemic and institutional issues would need to be fixed, and this could take decades to improve. However, a more short-term strategy that clinicians could assist minorities implement is emotion-focused coping. This strategy could lead to reduced emotion dysregulation and subsequently lower levels of anxious arousal. Such emotion regulation skills include: curbing impulsivity; accepting emotions; and setting goals. Moreover, Graham et al. (2021) note that therapists should pay particular attention to creating a supportive context for their clients so that they can discuss race-based traumatic experiences and the effects of these experiences on their clients’ lives.”[70] By more deeply understanding the prejudicial and discriminatory injustices associated with racial trauma, clinicians can more appropriately serve their clients to create lessened suffering and better therapeutic outcomes.

If you are experiencing anxiety or depression due to racism in any form (microaggressions, intergenerational trauma, workplace discrimination), please reach out to a mental healthcare provider.

For more information, click here to access an interview with Psychologist Michele Bedard-Gilligan on trauma & recovery.

Additionally, you may click here to access an interview with Psychologist Robyn Walser on trauma & addiction.

To access our PTSD Self-Care Tips, click here.

Contributed by: Nicole Izquierdo

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

References

1 Williams D. R. (2005). The health of U.S. racial and ethnic populations. The journals of gerontology. Series B, Psychological sciences and social sciences, 60 Spec No 2, 53–62. https://doi.org/10.1093/geronb/60.special_issue_2.s53

2 U.S. Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001.

3 Wells, K., Klap, R., Koike, A., & Sherbourne, C. (2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. The American Journal of Psychiatry, 158(12), 2027–2032. https://doi.org/10.1176/appi.ajp.158.12.2027

4 Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (2001). The quality of care for depressive and anxiety disorders in the United States. Archives of general psychiatry, 58(1), 55–61. https://doi.org/10.1001/archpsyc.58.1.55

5 Sue S, Zane N, Young K. Research on psychotherapy with culturally diverse populations. In: Garfield AEBSL, editor. Handbook of psychotherapy and behavior change. 4th edition. Vol 4. NY: Wiley & Sons; 1994. pp. 783–820.

6 Green, J. G., McLaughlin, K. A., Fillbrunn, M., Fukuda, M., Jackson, J. S., Kessler, R. C., Sadikova, E., Sampson, N. A., Vilsaint, C., Williams, D. R., Cruz-Gonzalez, M., & Alegría, M. (2020). Barriers to Mental Health Service Use and Predictors of Treatment Drop Out: Racial/Ethnic Variation in a Population-Based Study. Administration and policy in mental health, 47(4), 606–616. https://doi.org/10.1007/s10488-020-01021-6

7 Helms, J. E., Nicolas, G., & Green, C. E. (2010). Racism and ethnoviolence as trauma: Enhancing professional training. Traumatology, 16(4), 53-62. doi:10.1177/1534765610389595  

8 Carter, R. T., Mazzula, S., Victoria, R., Vazquez, R., Hall, S., Smith, S., . . . Williams, B. (2013). Initial development of the Race-Based Traumatic Stress Symptom Scale: Assessing the emotional impact of racism. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 1-9. doi:10.1037/a0025911  

9 https://dictionary.apa.org/intergenerational-trauma

10 Deangelis, A. (2019, February). The legacy of trauma. American Psychological 

Association. Vol 50, No. 2. Retrieved April 24, 2022, from https://www.apa.org/monitor/2019/02/legacy-trauma

11 Williams, M. T., Printz, D. M. B., & DeLapp, R. C. T. (2018). Assessing racial trauma with the Trauma Symptoms of Discrimination Scale. Psychology of Violence, 8(6), 735–747.

12 Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135(4), 531–554. https://doi.org/10.1037/a0016059

13 Gaertner, S. L., & Dovidio, J. F. (2006). Understanding and addressing contemporary racism: From aversive racism to the common ingroup. Journal of Social Issues, 61, 615–639. doi:10.1111/j.1540-4560.2005.00424.x.

14 Gehrman, E. (2019, November 20). Big Impact of Microaggressions. The Harvard Gazette. Retrieved April 24, 2022, from https://news.harvard.edu/gazette/story/2019/11/microaggressions-and-their-role-in-mental-illness/

15 Nadal, K. L., Griffin, K. E., Wong, Y., Hamit, S., & Rasmus, M. (2014). The impact of racial microaggressions on mental health: Counseling implications for clients of color. Journal of Counseling & Development, 92(1), 57–66. https://doi.org/10.1002/j.1556-6676.2014.00130.x

16 Ibid. 

17 Ibid. 

18 Ibid. 

19 Ibid.

20 Ibid. 

21 Fay, C. (2015). Effects of racial microaggressions on anxiety and depression in black and african american women (Order No. 3732015). Available from ProQuest Central; ProQuest Dissertations & Theses Global. (1734864063). Retrieved from https://login.proxy.lib.duke.edu/login?url=https://www.proquest.com/dissertations-theses/effects-racial-microaggressions-on-anxiety/docview/1734864063/se-2

22 Ibid. 

23 Liao, K. Y.-H., Weng, C.-Y., & West, L. M. (2016). Social connectedness and intolerance of uncertainty as moderators between racial microaggressions and anxiety among Black individuals. Journal of Counseling Psychology, 63(2), 240–246. https://doi.org/10.1037/cou0000123

24 Dugas, M. J., Buhr, K., & Ladouceur, R. (2004). The role of intolerance of uncertainty in the etiology and maintenance of generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: advances in research and practice (pp. 143–163). New York: Guilford Press.

25 Dugas, M. J., Gagnon, F., Ladoceur, R., and Freeston, M. H. (1998). Generalized anxiety disorder: a preliminary test of a conceptual model. Behav. Res. Ther. 36, 215–226. doi: 10.1016/S0005-7967(97)00070-3]

26 Liao et al. 2016

27 Choi, S., Clark, P. G., Gutierrez, V., Runion, C., & R, M. (2020). Racial microaggressions and Latinxs' well-being: A systematic review. Journal of Ethnic & Cultural Diversity in Social Work, 31(1), 16–27. https://doi.org/10.1080/15313204.2020.1827336 

28 Berry, O.O., Londoño Tobón, A. & Njoroge, W.F.M. Social Determinants of Health: the Impact of Racism on Early Childhood Mental Health. Curr Psychiatry Rep 23, 23 (2021). https://doi.org/10.1007/s11920-021-01240-0

29 Ibid. 

30 https://dictionary.apa.org/racism

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

32 Ibid. 

33 Ibid. 

34 Whitbeck, L. B., McMorris, B. J., Hoyt, D. R., Stubben, J. D., & Lafromboise, T. (2002). Perceived discrimination, traditional practices, and depressive symptoms among American Indians in the upper midwest. Journal of health and social behavior, 43(4), 400–418.

35 Hwang, W. C., & Goto, S. (2008). The impact of perceived racial discrimination on the mental health of Asian American and Latino college students. Cultural Diversity and Ethnic Minority Psychology, 14, 325–335. doi:10.1037/1099-9809.14.4.326.

36 Cuevas, A. G., Reitzel, L. R., Adams, C. E., Cao, Y., Nguyen, N., Wetter, D. W., Watkins, K. L., Regan, S. D., & McNeill, L. H. (2014). Discrimination, affect, and cancer risk factors among African Americans. American journal of health behavior, 38(1), 31–41. https://doi.org/10.5993/AJHB.38.1.4

37 Thames, A. D., Irwin, M. R., Breen, E. C., & Cole, S. W. (2019). Experienced discrimination and racial differences in leukocyte gene expression. Psychoneuroendocrinology, 106, 277–283. https://doi.org/10.1016/j.psyneuen.2019.04.016

38 Ong, A. D., & Williams, D. R. (2019). Lifetime discrimination, global sleep quality, and inflammation burden in a multiethnic sample of middle-aged adults. Cultural Diversity and Ethnic Minority Psychology, 25(1), 82–90. https://doi.org/10.1037/cdp0000233

39 Asian Pacific Policy and Planning Council (2020). In one month, STOP AAPI HATE Receives almost 1500 incident reports of verbal harassment, shunning and physical assaults. http://www.asianpacificpolicyandplanningcouncil.org/wp-content/uploads/Press_Release_4_23_20.pdf

40 Lopez, M. H., Gonzalez-Barrera, A., & Krogstad, J. M. (2020, May 30). Latinos' experiences with discrimination. Retrieved June 25, 2020, from https://www.pewresearch.org/hispanic/2018/10/25/latinos-and-discrimination/

41 F. (2019, September 22). Table 43. Retrieved June 25, 2020, from https://ucr.fbi.gov/crime-in-the-u.s/2018/crime-in-the-u.s.-2018/tables/table-43

42 Integrated Public Use Microdata Series, U.S. Census Data for Social, Economic, and Health Research, 2013-2017 American Community Survey: 5-year estimates (Minneapolis Minnesota Population Center, 2017), available at https://usa.ipums.org/usa/

43 Leavitt, R. A., Ertl, A., Sheats, K., Petrosky, E., Ivey-Stephenson, A., & Fowler, K. A. (2018). Suicides Among American Indian/Alaska Natives — National Violent Death Reporting System, 18 States, 2003–2014. MMWR. Morbidity and Mortality Weekly Report, 67(8), 237-242. doi:10.15585/mmwr.mm6708a1

44 Assari, S., Moazen-Zadeh, E., Caldwell, C. H., & Zimmerman, M. A. (2017). Racial discrimination during adolescence predicts mental health deterioration in adulthood: Gender differences among blacks. Frontiers in Public Health, 5. https://doi.org/10.3389/fpubh.2017.00104 

45 Ibid.

46 Caldwell, C. H., Antonakos, C. L., Tsuchiya, K., Assari, S., & De Loney, E. H. (2013). Masculinity as a moderator of discrimination and parenting on depressive symptoms and drinking behaviors among nonresident African-American fathers. Psychology of Men & Masculinity, 14(1), 47–58. https://doi.org/10.1037/a0029105

47 Sellers, R. M., & Shelton, J. N. (2003). The role of racial identity in perceived racial discrimination. Journal of Personality and Social Psychology, 84(5), 1079–1092. https://doi.org/10.1037/0022-3514.84.5.1079

48 Stein, G. L., Castro-Schilo, L., Cavanaugh, A. M., Mejia, Y., Christophe, N. K., & Robins, R. (2019). When Discrimination Hurts: The Longitudinal Impact of Increases in Peer Discrimination on Anxiety and Depressive Symptoms in Mexican-origin Youth. Journal of youth and adolescence, 48(5), 864–875. https://doi.org/10.1007/s10964-019-01012-3

49 Ibid.

50 Cuevas, A. G., Mann, F. D., Williams, D. R., & Krueger, R. F. (2020). Discrimination and anxiety: Using multiple polygenic scores to control for genetic liability. Proceedings of the National Academy of Sciences, 118(1). https://doi.org/10.1073/pnas.2017224118 

51 Alang, S., McAlpine, D., & McClain, M. (2021). Police Encounters as Stressors: Associations with Depression and Anxiety across Race. Socius. https://doi.org/10.1177/2378023121998128

52 Graham, A., Haner, M., Sloan, M. M., Cullen, F. T., Kulig, T. C., & Jonson, C. L. (2020). Race and worrying about police brutality: The hidden injuries of minority status in America. Victims & Offenders, 15(5), 549–573. https://doi.org/10.1080/15564886.2020.1767252 

53 Ibid. 

54 Alang et al. 2021

55 Metzger, I. W., Anderson, R. E., Are, F., & Ritchwood, T. (2021). Healing Interpersonal and Racial Trauma: Integrating Racial Socialization Into Trauma-Focused Cognitive Behavioral Therapy for African American Youth. Child maltreatment, 26(1), 17–27. https://doi.org/10.1177/1077559520921457

56 Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2013). Violence, crime, and abuse exposure in a national sample of children and youth: an update. JAMA pediatrics, 167(7), 614–621. https://doi.org/10.1001/jamapediatrics.2013.42

57 Ibid.

58 Sellers, R. M., Caldwell, C. H., Schmeelk-Cone, K. H., & Zimmerman, M. A. (2003). Racial identity, racial discrimination, perceived stress, and psychological distress among African American young adults. Journal of health and social behavior, 44(3), 302–317.

59 Metzger et al. 2021

60 Ibid. 

61 Lesane-Brown, C. L., Brown, T. N., Caldwell, C. H., & Sellers, R. M. (2005). The Comprehensive Race Socialization Inventory. Journal of Black Studies, 36(2), 163–190. https://doi.org/10.1177/0021934704273457

62 Metzger et al. 2021 

63 Ibid. 

64 Ibid. 

65 Ibid. 

66 Stevenson, H. C., Jr., Cameron, R., Herrero-Taylor, T., & Davis, G. Y. (2002). Development of the Teenager Experience of Racial Socialization scale: Correlates of race-related socialization frequency from the perspective of Black youth. Journal of Black Psychology, 28(2), 84–106. https://doi.org/10.1177/0095798402028002002

67 Grills, C., Cooke, D., Douglas, J., Subica, A., Villanueva, S., & Hudson, B. (2016). Culture, racial socialization, and positive African American youth development. Journal of Black Psychology, 42(4), 343–373. https://doi.org/10.1177/0095798415578004

68 Graham, J. R., Calloway, A. & Roemer, L. The Buffering Effects of Emotion Regulation in the Relationship Between Experiences of Racism and Anxiety in a Black American Sample. Cogn Ther Res 39, 553–563 (2015). https://doi.org/10.1007/s10608-015-9682-8

69 Hofmann, S. G., Sawyer, A. T., Fang, A., & Asnaani, A. (2012). Emotion dysregulation model of mood and anxiety disorders. Depression and Anxiety,29, 409–416. doi:10.1002/da.21888.

70 Graham et al. 2015

Mental Health and the Asian American Experience

Introduction

Historical Underpinnings

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

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

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

The Model Minority Myth: A Facade

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

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

The Pressure to Succeed

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

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

Self-Stigma and Self-Concealment: Difficulty Seeking Help

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

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

Possible Interventions

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

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

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

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

Contributed by: Anna Kiesewetter

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

References

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

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

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

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

5 Ibid.

6 Sue, 1993

7 Ibid.

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

9 Sue, 1993

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

11 Ibid.

12 Ibid.

13 Sue, 1993

14 Yi, 2016

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

16 Jung, 2021

17 Sue, 1993

18 Jung, 2021

19 Lee et al., 2008

20 Ibid.

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

22 Ibid.

23 Ibid.

24 Ibid.

25 Lee et al., 2008

26 Jung, 2021

27 Sue, 1993

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

29 Lee et al., 2008

30 Masuda & Boone, 2011

31 Ibid.

32 Sue, 1993

33 Lee et al., 2008

34 Sue, 1993

35 Yang et al., 2013

36 Sue, 1993