seattleanxiety

Climate Anxiety: The Psychological Impacts of Climate Change 

Are We Doomed?

Climate change refers to long-term changes in the Earth’s weather pattern and temperatures due to increased fossil fuel emissions. Studies have shown that humans have become the leading cause of climate change as the Earth’s surface is now around 1.1°C (2°F) warmer than in the 1800s. While that may not sound like a significant rise, the United Nations notes that it can lead to major environmental changes with catastrophic consequences including water scarcity, flooding, declining biodiversity, severe fires and storms.[1] Such dire warnings and predictions have led to psychological distress about what the future may hold. 

Climate Anxiety

Ecological anxiety (i.e., eco-anxiety) is the psychological discomfort arising from the threat of an ecological disaster, which itself is seen as uncertain or difficult to control. Climate change anxiety falls under the category of eco-anxiety and is explained as “the distress caused by climate change as people become anxious about their future.”[2] Nadarajah et al. (2022) note that climate change has become a source of concern for many international organizations including the United Nations and the World Health Organization (WHO) as they now consider this ecological threat to be the greatest danger to mental health within the next century.[3]  

The consequences humanity is already facing have been shown to have effects on their mental health and well-being. For example, excessive heat has been associated with increased aggression, suicide, and hospitalizations for mental illness. Air pollution caused by fine air particulate matter can lead to cognitive impairment and behavioral problems in vulnerable populations. Extreme heat and severe weather events also pose a greater risk to children’s development due to their thermoregulation not being fully developed and their greater dependency on adults and social support.[4] 

Climate anxiety can be caused due to either direct causes (e.g., trauma resulting from extreme weather events) or indirect causes (e.g., trauma from a perceived threat to the future). These causes can have different impacts on an individual’s symptoms of climate anxiety.  Cognitive-emotional impairments include difficulty sleeping, crying, nightmares, and rumination. Functional-impairments of climate anxiety include the inability to work or socialize with others.[5] Other mental health disorders have been associated with climate-related trauma such as post-traumatic stress disorder (PTSD), depression, anxiety, suicidal thoughts, and survivor guilt. Some individuals can even develop mood disorders or maladaptive eating due to the great uncertainty the future can hold and the intense fear that comes from questioning the future of their existence.[6]

Cross-National Investigation of Climate Anxiety 

While climate anxiety is just beginning to be studied, most research conducted has been done in Western, Educated, Industrialized, Rich Democracies (WEIRD). However, more emphasis is being drawn on the need for worldwide research on how global warming is affecting global populations psychologically. A 2021 study conducted in 50 different countries by Peoples’ Climate Vote found 64% of 1.2 million respondents believed climate change to be a global threat. Additionally, a survey conducted by Yale University in 2021 noted that the majority of people from over 30 countries felt climate change would affect them by either a “moderate amount” or a “great deal”.[7] Further, a 2021 poll conducted by Hickman et al., in the Global South found that Brazil (86%), India (80%), Nigeria (70%), and the Philippines (92%) all indicated high levels of fear for the future. Adversely, Russia reported some of the lowest concerns at 9.6%,[8] but this may be attributed to that population’s lack of climate-related information due to extreme internet/information censorship enacted by their government.[9] 

Due to the great fear of climate change, many studies, such as Ogunbode et al., (2022), have shown a direct relationship between climate anxiety and pro-environmental behaviors, such as supporting climate policies and climate activism. This is especially prominent among European, democratic, affluent countries - as their citizens are likely to have fewer political or financial barriers to expressing their concerns and have more opportunities to learn about global warming and its consequences. Additionally, pro-environmental behaviors are linked with individualist countries, as people feel a greater need to act on their personal beliefs.[10]

Generation Z &the Fear for Their Future 

While most climate anxiety research involves WEIRD countries, a global trend is beginning to emerge in cross-national data: Generation Z (i.e., those born 1997-2012) is more concerned with climate change than the generations before them. The Lancet Planetary Health (2021) conducted a global survey in 10 different countries asking young people (16 to 25 y/o) about their climate anxiety and their reaction to governmental response.[11] From this study, 83% of young people reported they were at least “moderately worried” and 59% reported they were “very worried” about global warming and its threat to the future. Additionally, 45% expressed that their worry affected their daily functioning such as concentrating, working, socializing, eating, and spending time in nature. The study also reveals respondents' fear for their future, with 75% indicating that the “future is frightening” and 56% feeling “humanity is doomed”.[12]

These pessimistic views are understandable, as Generation Z and those after will bear the harsh burden of climate change. A 2021 review by Hickman et al., found Gen-Z and future generations will face extremely high disease risk due to environmental changes. Hickman’s study also examined young people’s view on government response to climate change, and found respondents felt “frustrated by unequal power, betrayed and angry, and disillusioned with authority, drawing battle lines”.[13] The ecological crisis has gotten to the heart of younger populations, with one 16-year-old noting, “I think it’s different for young people. For us the destruction of the planet is personal.”[14] 

Young people have even turned to legal action in the hope of pushing the government to take action on the climate crisis. The case of Juliana v. United States was filed in 2015 after 21 children and young adults (8-19 y/o) asserted the government’s inaction on climate change was violating their right to life, liberty, and property. Additionally, the youth plaintiffs argued it was the government’s duty to protect public groups, which they failed to do as they permitted and encouraged fossil fuel usage.[15] However, in 2020 the case was thrown out stating the issue needed to be raised with the executive and legislative branches of government versus the courts.[16]

Many factors play into why this generation feels more strongly about climate change - the most prominent is media exposure. Younger generations are becoming more exposed to news, images, and reports of environmental disasters due to constant access to the internet and social media from their smartphones, and thus frequently witness the consequences of global warming.[17] Moreover, repeated exposure to negative news on climate change increases their awareness of the threat and increases their anticipation of the consequences. This then leads to additional information-seeking as a reactive behavior to the uncertainty of the future.[18] Finally, the social norms around climate change within younger generations are more pro-environmental, thus giving them a sense of security in their feelings. Ogunbode et al., (2022) add that when people around an individual react to the consequences in a similar way, they feel justified in their behaviors.[19]

Mitigating Climate Anxiety 

While the threat from climate change is a grave concern for many people, there are steps individuals can take to lower their anxiety as well as combat the crisis. Individuals can also decrease their climate anxiety as well as make a difference by supporting pro-environmental behaviors (e.g., saving energy at home, avoiding food waste, and using public transportation) and promoting policies and organizations that push to help the environment.[20] Taking pauses or meditating can also calm certain anxieties people may have about the climate crisis. Mindfulness can allow people to focus on the present moment and learn compassion for themselves and nature. Further, individuals can use contemplative time to reflect on the complexity of climate change, understand change cannot come overnight and can allow them to reflect on the power they hold to enact change and help make a difference. Psychotherapy, particularly cognitive behavioral therapy (CBT), can be useful for people to employ and work through their concerns with a mental health professional.[21] Particular components of CBT that can be useful in combating climate anxiety include:[22] 

  • Using problem-solving skills to cope with difficult situations

  • Learning to develop a greater sense of confidence in one’s own abilities

  • Facing one’s fears instead of avoiding them

  • Learning to calm one’s mind and relax one’s body

Additionally, individuals can seek clinicians who practice ecotherapy, or nature therapy, as these practitioners may have a greater awareness of current climate concerns. This is especially useful as ecotherapy focuses on reconnecting with nature and exploring how people’s lives are part of a greater system. If conducted in a group format, ecotherapy allows people to explore their personal relationships with nature as well as share with others their emotions and worries,[23] which can further validate their feelings and help someone feel less alone.

Future Steps 

Although climate anxiety is a relatively new concept, more emphasis needs to be placed on investigating the impacts of climate anxiety on non-WEIRD populations. Additionally, focusing on how different international factors such as education, religion, and region affects people’s feelings towards global warming will allow a better way to educate and create more effective strategies to help slow climate change.[24,25] Moving forward, it is imperative for mental health professionals to continue to develop strategies that allow clients to feel their concerns are being heard, as this phenomenon will only worsen as the consequences of climate change continue to rise. 

If you or someone you know is struggling with depression, hopelessness and/or anxiety regarding climate concerns, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

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

references

1 United Nations. (n.d.). What is climate change? | United Nations. https://www.un.org/en/climatechange/what-is-climate-change

2 Nadarajah, K., David, J., Brun, L., Bordel, S., Moyon, L., Foll, D. L., Delouvée, S., & Somat, A. (2022b). “We Are Running Out of Time”: Temporal Orientation and Information Seeking as Explanatory Factors of Climate Anxiety among Young People. Psych, 4(3), 560–573. https://doi.org/10.3390/psych4030043

3 Nadarajah et al., (2022)

4 Clayton, S. (2020). Climate anxiety: Psychological responses to climate change. Journal of Anxiety Disorders, 74. https://doi.org/10.1016/j.janxdis.2020.102263

5  Nadarajah et al., (2022)

6 Reyes, M. E. S., Carmen, B. P. B., Luminarias, M. E. P., Mangulabnan, S. a. N. B., & Ogunbode, C. A. (2021). An investigation into the relationship between climate change anxiety and mental health among Gen Z Filipinos. Current Psychology, 42(9), 7448–7456. https://doi.org/10.1007/s12144-021-02099-3 

7 Tam, K., Chan, H., & Clayton, S. (2023b). Climate change anxiety in China, India, Japan, and the United States. Journal of Environmental Psychology, 87, 101991. https://doi.org/10.1016/j.jenvp.2023.101991 

8 Hickman, C., Marks, E., Pihkala, P. P., Clayton, S., Lewandowski, R. J., Mayall, E. E., Wray, B., Mellor, C., & Van Susteren, L. (2021). Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. The Lancet Planetary Health, 5(12), e863–e873. https://doi.org/10.1016/s2542-5196(21)00278-3

9 Litvinova, D. (2023, May 24). The cyber gulag: How Russia tracks, censors and controls its citizens | AP News. AP News. https://apnews.com/article/russia-crackdown-surveillance-censorship-war-ukraine-internet-dab3663774feb666d6d0025bcd082fba 

10 Ogunbode, C. A., Doran, R., Hanss, D., Ojala, M., Salmela-Aro, K., Van Den Broek, K. L., Bhullar, N., De Aquino, S. D., Marot, T. A., Schermer, J. A., Wlodarczyk, A., Lu, S. L., Jiang, F., Maran, D. A., Yadav, R., Ardi, R., Chegeni, R., Ghanbarian, E., Z and, S., . . . Karasu, M. (2022). Climate anxiety, wellbeing and pro-environmental action: correlates of negative emotional responses to climate change in 32 countries. Journal of Environmental Psychology, 84, 101887. https://doi.org/10.1016/j.jenvp.2022.101887

11 Hickman et al., (2021) 

12 Ibid. 

13 Ibid. 

14 Ibid. 

15 Salas, R. N., Jacobs, W., & Perera, F. P. (2019). The Case of Juliana v. U.S. — Children and the Health Burdens of Climate Change. The New England Journal of Medicine, 380(22), 2085–2087. https://doi.org/10.1056/nejmp1905504

16 Youth climate lawsuit against federal government headed for trial. (2023). Yale E360. https://e360.yale.edu/digest/juliana-youth-climate-lawsuit-trial 

17 Nadarajah et al., (2022)

18 Ibid. 

19 Ogunbode et al., (2022) 

20 Ibid. 

21 Reyes et al., (2021) 

22 What is Cognitive Behavioral Therapy? (2017, July 31). https://www.apa.org. https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral  

23 GoodTherapy Editor Team. (2018, August 15). Ecotherapy/nature therapy. https://www.goodtherapy.org/learn-about-therapy/types/econature-therapy 

24 Tam et al., (2023)

25 Reyes et al., (2021) 

Perceived Social Support in School Environments During Adolescence

Nurturing Growth

Adolescence is one of the most formative periods of human development, a stage wherein many long-term habits and lifestyles are developed. It is marked by significant physical, cognitive, and socio-emotional changes.[1] Hellström & Beckman (2021) explain how understanding the needs and special challenges of this stage of life will bring about great benefits for solving and preventing unique problems in society.[2] As the majority of changes in adolescence come about through a combination of social, hormonal, cognitive circumstances (most of which occur in the environment of middle-high schools) Verhoeven et al. (2019) note this is an ideal time period to examine when looking for answers for questions about brain-behavior development.[3] 

As we increasingly concern ourselves with improving child educational environments and outcomes, Zhao et al. (2021) note that one of the biggest risk factors for adolescents’ academic motivation and achievement is the environment in their academic setting.[4] As Wang et al. found in 2020, positive classroom climate has been essential to many school reform efforts hoping to promote youth’s academic and psychological well-being.[5] Especially, the role of teacher support as a moderator for academic achievements among various types of learner is highlighted in importance. Supportive student-teacher relationships can help improve students’ self-schema and sense of belonging, and therefore enable them to productively achieve their personal goals.[6] So, how can we best support students and provide significant developmental opportunities?

Adolescent Social Support 

Farmer & Farmer (1996) explain how social support is the “processes of social exchange that contribute to the development of individuals’ behavioral patterns, social cognitions, and values”.[7] Hogan et al. (2002) have theorized two forms of social support, natural and formal, in which a natural social support network would consist of family and friends, while formal networks would include health professionals, religious or other social communities.[8] Specifically within an academic setting, social support refers to the perception of belonging and feeling cared for within a  support network of peers and teachers.[9] 

Perceived social support includes an individual's feeling of the availability and adequacy of support from their social network. Further, perceived social support is dependent on how individuals gauge the amount of emotional, informational, or tangible assistance they receive from their community.[10] Feeling a sense of social support is critical for promoting positive social, psychological, academic outcomes for students, and especially during adolescence with multiple transitions happening at once.[11] In an academic setting, where adolescents tend to spend much of their time (learning, socializing) this sense of perceived social support is especially important to find and be encouraged. According to Allen and Gregory (2018), social support is a significant buffer against negative experiences in life and stressors in the school environment, thus crucial in helping students cope with challenges, fostering a positive school climate, and ultimately promoting their academic and emotional well-being.[12] Danielsen et al. (2008) suggested that indirect support from teachers, classmates and parents can lead to student life satisfaction, and school-related support from teachers, classmates, parents have a direct effect on school satisfaction and scholastic competence in students.[13] 

Similar to social support, teacher’s confirmation positively predicts and has a noticeable influence on students’ emotional outcome. When teachers engage more, students seem less likely to exert unnecessary emotional efforts in the classroom; in contrast, if teachers display less or no interest or engagement in the classroom, students have a greater likelihood to expend emotional work, which bodes negatively for students achievement, motivation and other learning outcomes.[14] Specifically, emotion work is draining for students as it describes the extent to which students must expend emotional energy and perform emotional labor (i.e., faking or feigning emotions). In the context of the classroom, this can mean suppressing authentic emotions (e.g., anger, frustration, boredom) and displaying more socially acceptable ones.[15] Similarly, Spera (2005) found that parent support provides adolescents with a positive learning environment and instills a sense of responsibility and motivation. Peers can also provide emotional support, help with academic tasks, and serve as role models for positive behavior and achievement.[16]

However, there are multiple factors that mediate or moderate perceived social support and its outcomes in an academic environment beyond the student-teacher interactions; such factors include: 

  • Self-Esteem - Lau et al. (2018) conducted a study on the link between self-esteem and social support in first-year university students in Hong Kong and discovered that positive adjustments during the transition to college life increase when self-esteem is supported by peer and family social support. In particular, it offers a sense of security and represents an individual's importance to their social circle, in turn improving their self-esteem. Moreover, students with higher self-esteem may have higher aspirations and more resilience than those with lower self-esteem, therefore contributing to differing adjustment abilities.[17] These findings support those by Roman et al. in 2008, who found that self-esteem is positively correlated with effort and deep processing, which is the encoding of information in a meaningful and elaborate manner, facilitating long-term retention and retrieval. Vice versa, self-esteem is negatively related to shallow processing. It also has the strongest indirect positive effect on academic achievement through deep processing and effort.[18] 

  • Personality Traits - Personality traits play a significant role in shaping individuals' perceptions and experiences within their social environments.[19,20] A commonly used construct for analysis is the Big Five model of personality. The Big Five personality traits, (i.e., the five-factor model of personality) is a suggested personality taxonomy for personality traits developed in 1992 which postulates that there are five universal dimensions: Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience.[21] According to Swickert (2009), various personality dimensions are related to social support, including all of the Big Five personality traits. For example, agreeableness and extraversion seem to be most strongly positively correlated, while neuroticism (anger, irritability, self-doubt) has a strong negative correlation, with the perceived availability of social support.[22] Those with higher life satisfaction are also more extraverted, more sociable and more likely to experience pleasant moods.[23,24] 

  • Educational Goals - Hernandez et al. (2016) found that while social support has a positive and direct effect on academic performance, its influence also depends on the manner with which they treat this social support, like their personal goals and representation of this support.[25] In adolescents who mainly pursue social goals and neglect academic achievements, social support can influence inattention and lack of class participation. Additionally, social support predicts students’ investment and interest in work and success, but only if they are pursuing academic achievement.[26] This means that students’ effort in their school performance is in fact motivated by what they expect to get out of school, and attaching values to school for its emotional and relational opportunities detach students from academic expectations and demands. Therefore, in this way, social support can actually hinder them from achieving academic success. It is also important to note that elementary students report higher academic engagement and more social support from both family and school faculty than junior high school students.[27] It is therefore important that researchers and educators focus on the pleasures and importance of gaining knowledge throughout adolescence in order to redirect students’ motivation and achievement efforts in educational settings. 

  • Socioeconomic Status (SES) - Regarding the relationship between SES and academic achievements, Malecki & Demaray (2006) found that adolescents with lower SES tend to have corresponding lower GPA than those with higher SES.[28] However as a mitigating factor, students with lower SES have a significant positive relationship between GPA and social support - especially the social support of teacher.[29] To support this finding, a study conducted on low-income students by Wen & Li (2022) concluded that despite additional difficulties and risk factors these students face, higher levels of social support improved their academic performance by increasing dispositional optimism, which reflects positive perception of disadvantaged situations and the tendency to expect positive outcomes.[30] This “learned hopefulness” therefore underlines that individuals with higher perceived social support have more positive self-perceptions, including positive evaluations of their environment and more optimistic expectations of success.[31] 

Negative effects of negating social support

Even though there has been limited research done on the direct influence of the lack of social support and academic achievements in adolescents, studies have been conducted that may clue us into the nature of this relationship. For instance, Orban et al. (2020) studied the effects of social deprivation on adolescents’ development through the animal model of adolescent rodents.[32] They discovered that at the behavioral level, even a short period of isolation (e.g., 24 hours) in adolescent rodents can lead to heightened anxiety, increased hyperactivity, and a heightened sensitivity to social rewards, which extends to seeking food or drug rewards, making them more susceptible to developing addictions. Rodents that are chronically isolated throughout their entire adolescent period display abnormal behaviors such as hyper-reactivity to stressful situations and increased aggression. Moreover, isolation-induced changes also affect cognitive processes, such as learning and attention, resulting in reduced performance on tasks involving these processes. Specifically, isolation during adolescence leads to deficits in cognitive flexibility, impairing reward learning, reversal learning, and attention shifting.[33] Even though these results do not replicate exactly to human adolescents, they still inform us of the possible consequences of social isolation in adolescents’ mental wellbeing and cognitive development, which both influence their academic outcomes.[34] 

On a less extreme level of social support deprivation, findings from an experimental study on adult humans by Tomova et al. (2022) also suggest that social isolation results in increased feelings of loneliness, craving for social contact, and decreased happiness.[35] This is further supported by Glozah and Pevalin in 2014, who found that teenagers experiencing low psychological and physical wellbeing tend to resort to unhealthy coping mechanisms, such as absenteeism, truancy, and a general lack of motivation towards their studies.[36] Additionally, compromised health and psychological well being can contribute to attention issues, subsequently affecting academic performance and making it challenging for students to cope with academic pressures.[37]

Considering these findings, it is possible that without a strong network of social support in school, adolescents may be negatively affected not only academically, but also in terms of cognitive development and mental well-being. Given the current gap in knowledge, however, further studies on the potential effects of social support deprivation in adolescents are imperative. 

Potential interventions 

It is thus crucial for us as individuals and institutions to focus on creating an academic space in which social support is optimally available to adolescents. 

In 2007, the World Health Organization (WHO) listed efforts that have been implemented globally to improve social support and help-seeking behaviors in adolescents in an international literature review and program consultation.[38] Some schools have reported a strategy for improving students’ health and attracting them to existing services by experimenting with making local services more “adolescent-friendly” by offering more suitable hours and hiring training staff in adolescent-specific needs.[39] Another way of offering more convenience for adolescents is by locating/relocating health services to attract them, such as building more school-based health clinics. In addition to this, some countries offer adult outreach or community health promoters, who have been employed to bring health services and information to adolescents at home or at school.[40] However, they point out that in already overburdened public education systems, it can be difficult to aid adolescents’ use of public health resources.[41] 

The report also noted the use of peer promoters, which includes the training and supervising of adolescents or young adults to introduce health-related information to their peers to promote help-seeking.[42] Dougherty & Sharkey (2017) has also provided literature in favor of these peer programs and peer support groups for those with specific health needs, such as substance use or violence.[43] Along this line, information campaigns, hotlines and information centers have also long been carried out to increase awareness on support resources for adolescents and can provide youth with information on existing local resources, services, job training, and recreational activities.[44] 

In several countries, service integration also exists, which is the formal or informal networks among existing services, as a strategy for promoting help-seeking by adolescents with the goal of casting a broader net for social support.[45] However, this service is often built upon the premise that infrastructure exists and can be integrated to increase access. The underlying framework is that through collaboration, this social support network can become larger than the sum of its parts, thus in theory more effective.[46] 

In support of this, a study conducted by Lee et al. (1999) in Chicago found that when seeking to improve students’ academic performance, school systems should not ignore social support as a pertinent factor that contributes to students' success.[47] For those who may receive especially little support from their local community, peers, and at home, it is even more important that school staff create academic environments that are supportive for learning. Similarly, looking to improve students’ achievements by fostering supportive environments alone is insufficient. The report found that without academic press in school, social support alone may not lead to meaningful improvements in academic performance.[48] 

Specifically for social support, some schools within the Chicago Annenberg Research Project have created smaller, more personalized classrooms (e.g., school-within-schools, teachers teaching the same cohort for multiple grades, supplemental one-on-one tutoring with teacher assistants). Some schools provide teachers with professional development opportunities to encourage supportive relationships with students, others strengthen support through parent education programs, engaging parents in classroom activities and one-on-one student mentorships. Several schools have given students the opportunities to develop relationships with local community members who can support and guide them as role models, or increase peer relationships through extracurricular activities.[49] 

For academic purposes, schools have turned to communicating high learning expectations and clear responsibilities for students. This has also been accomplished by professional development for teachers aiming at improving quality of instruction and guiding students towards more challenging work and critical thinking. Some schools have developed incentive systems to reward students for high academic achievements or student assessments that have a double-pronged purpose: student-teacher accountability and the teacher’s own examination of their teaching style for improvements.[50] 

While these options can offer increased social support for students, they do not come without substantial challenges and school systems may not have the time and resources currently available to enact these changes.[51,52] 

Therefore, more research should be done to bring awareness to these approaches and develop more easily applicable and less costly methodologies. The WHO notes that these efforts, whether it be research or application, should also involve meaningful participation of adolescents, as junior researchers.[53,54] As the Kellogg Foundation cited in 1998, some of the key needs when it comes to initiatives promoting support-seeking from adolescents include the need to:[55] 

  • Identify service barriers 

  • Have detailed written agreements and plans to services 

  • Consider culturally appropriate models of support 

  • Work with existing community resources.

Through increased awareness and opportunities, social support within school environments can help adolescents’ mental health and educational opportunities.

If you or your loved ones are looking for ways to provide additional support for your child, or if they seem to be struggling in school, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance. 

Contributed by: Mai Tran

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

References

1 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on the Neurobiological and Socio-behavioral Science of Adolescent Development and Its Applications. The Promise of Adolescence: Realizing Opportunity for All Youth. Backes EP, Bonnie RJ, editors. Washington (DC): National Academies Press (US); 2019 May 16. PMID: 31449373.

2 Hellström L, Beckman L. Life Challenges and Barriers to Help Seeking: Adolescents' and Young Adults' Voices of Mental Health. Int J Environ Res Public Health. 2021 Dec 12;18(24):13101. doi: 10.3390/ijerph182413101. PMID: 34948711; PMCID: PMC8700979.

3 Verhoeven, M., Poorthuis, A.M.G. & Volman, M. The Role of School in Adolescents’ Identity Development. A Literature Review. Educ Psychol Rev 31, 35–63 (2019). https://doi.org/10.1007/s10648-018-9457-3

4 Zhao, K., Chen, N., Liu, G., Lun, Z., & Wang, X. (2023). School climate and left-behind children’s achievement motivation: The mediating role of learning adaptability and the moderating role of teacher support. Frontiers in Psychology, 14. https://www.frontiersin.org/articles/10.3389/fpsyg.2023.1040214

5 Wang, M.-T., L. Degol, J., Amemiya, J., Parr, A., & Guo, J. (2020). Classroom climate and children’s academic and psychological wellbeing: A systematic review and meta-analysis. Developmental Review, 57, 100912. https://doi.org/10.1016/j.dr.2020.100912

6 Zhao et al. (2023)

7 Farmer, T. W., & Farmer, E. (1996). Social relationships of students with exceptionalities in mainstream classrooms: Social networks and homophily. Exceptional Children, 62, 431-450.

8 Hogan, B. E., Linden, W., & Najarian, B. (2002). Social support interventions: Do they work? Clinical Psychology Review, 22(3), 381–440. https://doi.org/10.1016/S0272-7358(01)00102-7

9 Grapin, S.L., Sulkowski, M.L. & Lazarus, P.J. A Multilevel Framework for Increasing Social Support in Schools. Contemp School Psychol 20, 93–106 (2016). https://doi.org/10.1007/s40688-015-0051-0

10 Farmer, A. & Farmer, S. (1996). Motivational Influences on Social Cognition and Aggressive Behavior. In D.J. Pepler & K.H. Rubin (Eds.), The Development and Treatment of Childhood Aggression (pp. 433-455). Hillsdale, NJ: Lawrence Erlbaum Associates.

11 Bauer A, Stevens M, Purtscheller D, Knapp M, Fonagy P, Evans-Lacko S, Paul J. Mobilising social support to improve mental health for children and adolescents: A systematic review using principles of realist synthesis. PLoS One. 2021 May 20;16(5):e0251750. doi: 10.1371/journal.pone.0251750. PMID: 34015021; PMCID: PMC8136658.

12 Allen, J. P., & Gregory, A. (2018). Social support as a buffer for perceived racial discrimination stress among African American youth. Journal of Research on Adolescence, 28(4), 1015-1030. doi:10.1111/jora.12385

13 Danielsen, A. G., Samdal, O., Hetland, J., & Wold, B. (2009). School-related social support and students' perceived life satisfaction. The Journal of Educational Research, 102(4), 303–318. https://doi.org/10.3200/JOER.102.4.303-320

14 Goldman, Z. W., & Goodboy, A. K. (2014). Making students feel better: Examining the relationships between teacher confirmation and college students' emotional outcomes. Communication Education, 63(3), 259–277. https://doi.org/10.1080/03634523.2014.920091

15 Titsworth, S., Quinlan, M. M., & Mazer, J. P. (2010). Emotion in teaching and learning: Development and validation of the Classroom Emotions Scale. Communication Education, 59, 431–452. doi:10.1080/03634521003746156

16 Spera, C. (2005). A review of the relationship among parenting practices, parenting styles, and adolescent school achievement. Educational Psychology Review, 17(2), 125-146. doi:10.1007/s10648-005-3950-1

17 Lau, E.Y.H., Chan, K.K.S., & Lam, C.B. (2018). Social Support and Adjustment Outcomes of First-Year University Students in Hong Kong: Self-Esteem as a Mediator. Journal of College Student Development 59(1), 129-134. doi:10.1353/csd.2018.0011.

18 Román, S., Cuestas Díaz, P., & Fenollar, P. (2008). An examination of the interrelationships between self-esteem, others’ expectations, family support, learning approaches and academic achievement. Studies in Higher Education, 33, 127–138. https://doi.org/10.1080/03075070801915882

19 Ali, I. (2019). Personality traits, individual innovativeness and satisfaction with life. Journal of Innovation & Knowledge, 4(1), 38–46. https://doi.org/10.1016/j.jik.2017.11.002

20 The Importance of Personality Traits in Students' Perceptions of Metacognitive Awareness. (2016). Procedia - Social and Behavioral Sciences, 232, 655–667. https://doi.org/10.1016/j.sbspro.2016.10.090

21 Costa, P T. & McCrae, R. (1992) Revised NEO Personality Inventory (NEO-PI-R) and NEO Five Factor Model (NEO-FFI) Professional manual. Odesa, FL; Psychological Assessment Center.

22 Swickert, R. (2009). Personality and social support. In P. Corr & G. Matthews (Eds.), Cambridge handbook of personality (pp. 524–540). Cambridge, England: Cambridge University Press.

23 Potash M.. Noppe 1. and Noppe L. (1981) The relationship of personality factors to life satisfaction among the elderly. Paper presented at the Annual Meeting of the Gerontological Society of America, Toronto.

24 Emmons R. A. and Diener E. (1986) Influence of impulsivity and sociability on subjective well-being. J. Person. sot. PsJchol. 50, 121 I-1215. family environment generalized to new social relationships? Cognitive Therapy and Research, 18, 39–53.

25 Hernandez, L., Oubrayrie-Roussel, N. & Prêteur, Y. Educational goals and motives as possible mediators in the relationship between social support and academic achievement. Eur J Psychol Educ 31, 193–207 (2016). https://doi.org/10.1007/s10212-015-0252-y

26 Ibid.

27 Rueger SY, Malecki CK, Demaray MK. Relationship between multiple sources of perceived social support and psychological and academic adjustment in early adolescence: comparisons across gender. J Youth Adolesc. 2010 Jan;39(1):47-61. doi: 10.1007/s10964-008-9368-6. Epub 2008 Dec 9. PMID: 20091216.

28 Malecki, C. K., & Demaray, M. K. (2006). Social support as a buffer in the relationship between socioeconomic status and academic performance. School Psychology Quarterly, 21(4), 375–395. https://doi.org/10.1037/h0084129

29 Ibid.

30 Wen, X., & Li, Z. (2022). Impact of Social Support Ecosystem on Academic Performance of Children From Low-Income Families: A Moderated Mediation Model. Frontiers in Psychology, 13. https://www.frontiersin.org/articles/10.3389/fpsyg.2022.710441

31 Ibid.

32 Orben A, Tomova L, Blakemore SJ. The effects of social deprivation on adolescent development and mental health. Lancet Child Adolesc Health. 2020 Aug;4(8):634-640. doi: 10.1016/S2352-4642(20)30186-3. Epub 2020 Jun 12. PMID: 32540024; PMCID: PMC7292584.

33 Ibid.

34 Ibid.

35 Tomova L, Wang KL, Thompson T, Matthews GA, Takahashi A, Tye KM, Saxe R. Acute social isolation evokes midbrain craving responses similar to hunger. Nat Neurosci. 2020 Dec;23(12):1597-1605. doi: 10.1038/s41593-020-00742-z. Epub 2020 Nov 23. Erratum in: Nat Neurosci. 2022 Mar;25(3):399. PMID: 33230328; PMCID: PMC8580014.

36 Glozah, F. N., & Pevalin, D. J. (2014). Social support, stress, health, and academic success in Ghanaian adolescents: A path analysis. Journal of Adolescence, 37(4), 451–460. https://doi.org/10.1016/j.adolescence.2014.03.010

37 Barriga, A., Doran, J., Newell, S., Morrison, E., Barbetti, V., & Robbins, B. (2002). Relationships Between Problem Behaviors and Academic Achievement in AdolescentsThe Unique Role of Attention Problems. Journal of Emotional and Behavioral Disorders - J EMOTIONAL BEHAV DISORD, 10, 233–240. https://doi.org/10.1177/10634266020100040501

38 Barker, Gary. (‎2007)‎. Adolescents, social support and help-seeking behaviour : an international literature review and programme consultation with recommendations for action / Gary Barker. World Health Organization. https://apps.who.int/iris/handle/10665/43778

39 Ibid.

40 Ibid.

41 Ibid.

42 Ibid.

43 Dougherty, D., & Sharkey, J. (2017). Reconnecting Youth: Promoting emotional competence and social support to improve academic achievement. Children and Youth Services Review, 74, 28–34. https://doi.org/10.1016/j.childyouth.2017.01.021

44 Barker (2007)

45 Ibid.

46 Costello J, Pickens L & Fenton J (2001). Social supports for children and families: A matter of connections.Chicago, Chapin Hall Centre for Children at the University of Chicago (Draft manuscript).

47 Lee, V. E., Smith, J. B., Perry, T. E., & Smylie, M. A. (1999). Social Support, Academic Press, and Student Achievement: A View from the Middle Grades in Chicago. Improving Chicago’s Schools. A Report of the Chicago Annenberg Research Project. Consortium on Chicago School Research, 1313 E. https://eric.ed.gov/?id=ED439213

48 Ibid.

49 Ibid.

50 Ibid.

51 Griffith, M. (2018). What is the cost of providing students with adequate psychological support. National Association of School Psychologists (NASP). https://www.nasponline.org/research-and-policy/policy-matters-blog/what-is-the-cost-of-providing-students-with-adequate-psychological-support  

52 Barker (2007)

53 Ibid.

54 Bauer, A., Stevens, M., Purtscheller, D., Knapp, M., Fonagy, P., Evans-Lacko, S., & Paul, J. (2021). Mobilising social support to improve mental health for children and adolescents: A systematic review using principles of realist synthesis. PLOS ONE, 16(5). https://doi.org/10.1371/journal.pone.0251750  

55 Kellogg Foundation (1998). Safe Passages through Adolescence: Communities Protecting the Health and Hopes of Youth. In Lessons Learned from WK Kellogg Foundation Programming. Battle Creek,MI, USA.

How Mortality Changes Our Behaviors: Insights from Death Anxiety Research

Reminders of Death

Everyone eventually dies. Despite this commonality, psychologists like Gordillo et al., (2007) have found that being reminded of our own demise (i.e., mortality salience) can change several of our thoughts and behaviors due to the emergence of imminent death anxiety.[1] Whether we are aware of it or not, we typically become more fearful and sad following death reminders, and our behavior is subsequently impacted[2] as we work towards protecting ourselves through self-preservation. Fritsche et al. (2007) found an increase in reproductive behaviors and desire for offspring and Rosenblatt et al. (1989) found an increase in the defensiveness of culturally-upheld values after mortality becomes salient.[3,4] These findings relate to the evidence-based Terror Management Theory (TMT), which states that death anxiety is a primary motivator for all human behaviors.[5] TMT adds that every culture preserves ideas of immortality to reduce the feelings of this “terror” or anxiety such as memorials, symbolic afterlives and statues. Death anxiety and its impacts on people provide insight into several processes of the human condition as well as mental health treatment and practice.

Mortality Salience in Everyday Life

Presentations of mortality salience (MS) may appear as: viewing a cemetery on the way to work, witnessing constant sickness and death as a healthcare worker, viewing violence and danger on television, seeing an ambulance on the freeway, or anything that may remind someone of their own danger. By fMRI (functional magnetic resonance imaging), the parts of the brain that can be activated after MS include the prefrontal cortex (involved in self-regulation), to regulate and motivate defense of concerns of death.[6] The right amygdala (important for emotional processing), and the behavioral inhibition system (BIS) as well as general anxiety systems, are also involved.[7] Xu et al. (2022) found that MS also increases activation in areas of the brain regarding guilt and shame as one experiences death anxiety.[8]

Changed Behaviors

Cultural Values 

A person’s thoughts and behaviors typically change after they are reminded of their mortality. When self-esteem (i.e., a person's sense of their worth) is high, it is found to be a protective buffer against fears surrounding death.[9,10] Furthermore, Basset & Bussard (2021) found that the strength of one’s religious beliefs and actions increases as fears of death conversely decrease, suggesting that religion can help protect oneself from death anxiety and boost self-esteem.[11,12] 

The impact of the perceived mortality reminder also depends on whether it was felt individually or collectively. Utilizing data across 79 countries, Fog (2023) found that mortality salience of individual danger (danger to oneself) reveals increased religious behavior but no effect on religious beliefs, less regard toward authorities and less nationalism.[13] On the contrary, perceived collective danger (danger to a group of people including oneself) tends to result in increased nationalism, traditionalism, security, religiosity and strict sexual morals.[14] Additionally, Rosenblatt et al. (1989) found that after mortality salience, judges fined prostitutes more and declared harsher punishments, upholding negative views toward prostitution while promoting culturally conservative values.[15] Rosenblatt et al. also found that people promote “heroism” following MS. They found that college students that were primed with a death reminder (when compared with a control group) gave three times as large of a reward to a fictional hero as well as a more severe punishment to a fictional non-violent criminal.[16] 

Decreased Altruism

Possibly in an effort to maintain self-preservation, reminders of death tend to lessen a person’s altruism (i.e., behavior that is unselfishly beneficial to others).[17] Kheibari et al. (2023) found that those with low self-esteem, tend to develop increased stigma about suicide once they face MS.[18] In addition, respondents reported a lower likelihood to intervene and try to prevent another’s suicide, and they responded that they would allocate less money to suicide prevention organizations.[19] 

Risk-Taking and Safety Behavior

Being reminded of death has risk-taking implications. Weng et al. (2023) found that among publicly traded firms in the United States, MS inflicted on the director or CEO led to decreased long-term investment by firms.[20] Bessarabora & Massey (2023) also found that MS produced adaptive opinions towards texting and driving, resulting in greater attempts at safe driving and self-preservation.[21] Li et al. (2023) note that people were impacted by the death anxiety caused by negative media exposure during the COVID-19 pandemic.[22] As a result, employees were shown to follow increased human resources practices (e.g., workplace safety behaviors) during the pandemic.[23] In an effort of self-preservation, death anxiety also enhances consumer purchasing desires, alluding to practical applications regarding marketing and advertising.[24] Emergency-related death anxiety from the COVID-19 pandemic additionally led to studies involving panic shopping (i.e., “consumer misbehavior”) as people feverishly sought to stock up on perceived essentials necessary for survival.[25] By collecting responses from 400 consumers that shopped during the pandemic, Scarpi et al. (2023) found that death anxiety impacted customers’ awareness of their shopping misbehavior and individual responsibility.[26] 

Relationships and Attachment

Following a death reminder, Plusnin et al. (2018) note that close relationships were found to be a way of reducing death anxiety similar to self-esteem’s buffer function.[27] Mental accessibility of words related to attachment is also increased after MS, in addition to commitment to a partner and the desire for psychological intimacy.[28] 

Death Anxiety’s Purpose and Relevance

Many elements of an individual’s life are impacted by a reminder of death, yet how this actually functions is less known. Many models are proposed based on sociological, anthropological, philosophical, and neurological evidence (including TMT) making this field extremely interdisciplinary. 

Reasons why death anxiety affects so many human behaviors may relate to legacy motivations[29] and the desire for one’s legacy to last through familial and generational knowledge (akin to symbolic immortality). This perceived immortality through remembrance may act as a coping mechanism to overcome death anxiety and[30] many cultures seek symbolic immortality by preserving life as never-ending through modes such as religion, art and rituals. 

Psychopathology and Death Anxiety

Death anxiety creates a sense of powerlessness and meaninglessness in life and coping mechanisms to combat these sensibilities can sometimes be more hurtful than helpful (such as avoidance) and are correlated with many psychiatric disorders.[31] For instance, existential anxiety may help drive, cause, or sustain many anxiety disorders including:[32]

Research with anxiety disorders will typically prime individuals with a death reminder and observe an increased perceived threat and maladaptive behaviors within individuals when presented with anxiety-provoking stimuli, as opposed to when presented with no death reminder.[33] In addition to promoting a range of anxiety disorders, death anxiety can be a factor in:[34]

The frequency of death-related thoughts is typically increased for individuals with such disorders. Additionally, those with substance abuse disorders may engage in self-medication as a form of maladaptive coping with death anxiety, as Menzies & Menzies (2023) note that among people with substance abuse disorders, increased symptom severity correlates with higher existential anxiety.[35] 

Treating Death Anxiety

While death anxiety seems to be an inevitable and even unconscious element of being human, an exceeding amount of it may factor into impairment in life. Death anxiety was found to predict psychosis[36] among many mental disorders and targeting death anxiety, itself, may be a way to prevent and treat subsequent life impairments. 

Menzies & Menzies (2023) note that Cognitive Behavioral Therapy (CBT) has been useful in reducing death-related anxiety through methods such as Exposure Therapy that allow patients to confront their fears surrounding death.[37] Death “thought-reframing” has also been employed to encourage positive adaptive coping with death anxiety.[38] Acceptance and Commitment Therapy (ACT), a modality used to focus on awareness of mental states and thoughts, may also be a way for clients to reflect on the meaning of their lives and restore this from what was lost in experiences of death anxiety.[39,40] Relating to Buddhist thought and practice, Anālayo et al. (2022) found that mindfulness also reduces death anxiety through facing mortality, which simultaneously increases self-compassion.[41] 

Death anxiety takes implicit and explicit forms that range from completely expected to life-impairing. Its empirical insights may lead to a holistic perspective of human behavior. Being mindful of these findings may include applying them to practical situations such as justice systems and hospital employees. Aldiabat et al. (2023) note that consideration for perceptions of death and death reminders is relevant to nurses and other healthcare workers for how MS may impact their actions in practice.[42] Further research in the field, including death anxiety and psychiatric disorders, may also open doors for clinical treatment to target existential anxiety, particularly for middle-aged adults, seniors and those with chronic or terminal illnesses. 

If one is experiencing death anxiety that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

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

References

1 Gordillo, F., Mestas, L., Arana, J. M., Pérez, M. Á., & Escotto, E. A. (2017). The Effect of Mortality Salience and Type of Life on Personality Evaluation. Europe's journal of psychology, 13(2), 286–299. https://doi.org/10.5964/ejop.v13i2.1149

2 Huang, C., & Hu, C. (2023). The terror management and sorrow management of death consciousness. Acta Psychologica Sinica, 55(2), 318-335. doi:10.3724/SP.J.1041.2023.00318

3 Fritsche I, Jonas E, Fischer P, Koranyi N, Berger N, Fleischmann B. Mortality salience and the desire for offspring. Journal of Experimental Social Psychology. 2007;43:753–62. https://scholar.google.com/scholar_lookup?journal=Journal+of+Experimental+Social+Psychology&title=Mortality+salience+and+the+desire+for+offspring&author=I+Fritsche&author=E+Jonas&author=P+Fischer&author=N+Koranyi&author=N+Berger&volume=43&publication_year=2007&pages=753-62&

4 Rosenblatt, A., Greenberg, J., Solomon, S., Pyszczynski, T., & Lyon, D. (1989). Evidence for terror management theory: I. The effects of mortality salience on reactions to those who violate or uphold cultural values. Journal of personality and social psychology, 57(4), 681–690. https://doi.org/10.1037//0022-3514.57.4.681

5 Greenberg, J., Solomon, S., Pyszczynski, T., Rosenblatt, A., Burling, J., Lyon, D., Simon, L., & Pinel, E. (1992). Why do people need self-esteem? Converging evidence that self-esteem serves an anxiety-buffering function. Journal of personality and social psychology, 63(6), 913–922. https://doi.org/10.1037//0022-3514.63.6.913

6 Silveira, S., Graupmann, V., Agthe, M., Gutyrchik, E., Blautzik, J., Demirçapa, I., Berndt, A., Pöppel, E., Frey, D., Reiser, M., & Hennig-Fast, K. (2014). Existential neuroscience: effects of mortality salience on the neurocognitive processing of attractive opposite-sex faces. Social cognitive and affective neuroscience, 9(10), 1601–1607. https://doi.org/10.1093/scan/nst157

7 Ibid.

8 Xu, Z., Zhu, R., Zhang, S., Zhang, S., Liang, Z., Mai, X., & Liu, C. (2022). Mortality salience enhances neural activities related to guilt and shame when recalling the past. Cerebral Cortex (New York, N.Y.: 1991), 32(22), 5145-5162. doi:10.1093/cercor/bhac004   

9 Greenberg et al. (1992)

10 E.G. Hepper, Self-Esteem, Editor(s): Howard S. Friedman, Encyclopedia of Mental Health (Second Edition), Academic Press, 2016, Pages 80-91, ISBN 9780123977533, https://doi.org/10.1016/B978-0-12-397045-9.00076-8

11 Bassett, J. F., & Bussard, M. L. (2021). Examining the Complex Relation Among Religion, Morality, and Death Anxiety: Religion Can Be a Source of Comfort and Concern Regarding Fears of Death. OMEGA - Journal of Death and Dying, 82(3), 467–487. https://doi.org/10.1177/0030222818819343 

12 Szcześniak, M., & Timoszyk-Tomczak, C. (2020). Religious Struggle and Life Satisfaction Among Adult Christians: Self-esteem as a Mediator. Journal of religion and health, 59(6), 2833–2856. https://doi.org/10.1007/s10943-020-01082-9

13 Fog, A. (2023). Psychological and cultural effects of different kinds of danger. An exploration based on survey data from 79 countries, Culture and Evolution (published online ahead of print 2023). doi: https://doi.org/10.1556/2055.2023.00029

14 Ibid.

15 Rosenblatt et al. (1989)

16 Ibid.

17 Kheibari, A., & Cerel, J. (2023). The Role of Death Anxiety and Self-Esteem in Suicide Attitudes. OMEGA - Journal of Death and Dying, 86(3), 1069–1088. https://doi-org.colby.idm.oclc.org/10.1177/00302228211000935 

18 Ibid.

19 Ibid. 

20 Weng, D. H., & Kim, K. H. (2023). Letting go or pushing forward: Director death and firm risk-taking. Long Range Planning, 56(3), 102322. ISSN 0024-6301. https://doi.org/10.1016/j.lrp.2023.102322.

21 Bessarabova, E., & Massey, Z. B. (2023). The effects of death awareness and reactance on texting-and-driving prevention. Risk Analysis, 00, 1– 13. https://doi-org.colby.idm.oclc.org/10.1111/risa.14107 

22 Li, S., Young, H.R., Ghorbani, M. et al. Keeping Employees Safe During Health Crises: The Effects of Media Exposure, HR Practices, and Age. J Bus Psychol 38, 457–472 (2023). https://doi.org/10.1007/s10869-022-09837-9

23 Ibid.

24 Menzies, R. E., & Menzies, R. G. (2023). Death anxiety and mental health: Requiem for a dreamer. Journal of Behavior Therapy and Experimental Psychiatry, 78, 101807. ISSN 0005-7916. https://doi.org/10.1016/j.jbtep.2022.101807

25 Scarpi, D., Pantano, E. and Marikyan, D. (2023), "Consumers' (ir)responsible shopping during emergencies: drivers and concerns", International Journal of Retail & Distribution Management, Vol. 51 No. 6, pp. 791-806. https://doi.org/10.1108/IJRDM-08-2022-0300 

26 Ibid. 

27 Plusnin, N., Pepping, C. A., & Kashima, E. S. (2018). The Role of Close Relationships in Terror Management: A Systematic Review and Research Agenda. Personality and Social Psychology Review, 22(4), 307–346. https://doi.org/10.1177/1088868317753505

28 Ibid.

29 Waggoner, B., Bering, J. M., & Halberstadt, J. (2023). The desire to be remembered: A review and analysis of legacy motivations and behaviors. New Ideas in Psychology, 69, 101005. ISSN 0732-118X. https://doi.org/10.1016/j.newideapsych.2022.101005

30 Ibid.

31 Menzies, R. E., & Menzies, R. G. (2023). Death anxiety and mental health: Requiem for a dreamer. Journal of Behavior Therapy and Experimental Psychiatry, 78, 101807. ISSN 0005-7916. https://doi.org/10.1016/j.jbtep.2022.101807

32 Ibid.

33 Ibid.

34 Ibid.

35 Ibid.

36 Easden, D., Gurvich, C., Kaplan, R. A., & Rossell, S. L. (2023). Exploring fear of death and psychosis proneness: Positive schizotypy as a function of death anxiety and maladaptive coping. Clinical Psychologist, 27(1), 35-44. DOI:10.1080/13284207.2022.2070426. 

37 Menzies & Menzies (2023)

38 Ibid. 

39 Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. International journal of clinical and health psychology : IJCHP, 18(1), 60–68. https://doi.org/10.1016/j.ijchp.2017.09.002 

40 Ibid.

41 Anālayo, B., Medvedev, O.N., Singh, N.N. et al. Effects of Mindful Practices on Terror of Mortality: A Randomized Controlled Trial. Mindfulness 13, 3043–3057 (2022). https://doi.org/10.1007/s12671-022-01967-8 

42 Aldiabat, K., Alsrayheen, E. A., & Le Navenec, C. -. (2023). Death anxiety among older adults during the COVID-19 pandemic: Implications for nursing practice. Universal Journal of Public Health, 11(1), 89-96. doi:10.13189/ujph.2023.110110  

Narrative Therapy: Integrating Humanistic Storytelling Into Mental Healthcare

Storytelling in Medicine

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

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

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

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

Theories of Narrative Therapy

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

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

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

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

Narrative Therapy in Practice

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

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

  • Deconstruction 

  • Externalization

  • Reauthoring

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

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

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

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

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

Benefits and Applications of Narrative Therapy

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

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

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

Limitations of Narrative Therapy

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

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

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

Contributed by: Anna Kiesewetter

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

References

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

2 Ibid.

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

4 Charon (2001)

5 Ibid. 

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

7 Roberts (2000)

8 Ibid.

9 Charon (2001)

10 Ibid. 

11 Ibid. 

12 Ibid.

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

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

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

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

17 Koganei et al. (2021)

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

19 Koganei et al. (2021)

20 Stahnke & Cooley (2022)

21 Roberts (2000)

22 Ibid.

23 Ibid. 

24 Ibid.

25 Ibid. 

26 Stahnke & Cooley (2022)

27 Tadros et al. (2022)

28 Williams-Reade et al. (2014)

29 Tadros et al. (2022)

30 Stahnke & Cooley (2022)

31 Tadros et al. (2022)

32 Stahnke & Cooley (2022)

33 Tadros et al. (2022)

34 Stahnke & Cooley (2022)

35 Roberts (2000)

36 Ibid.

37 Koganei et al. (2021)

38 Ibid.

39 Stahnke & Cooley (2022)

40 Ibid.

41 Roberts (2000)

42 Ibid.

43 Ibid.

Xenophobia and Mental Health in Asian Americans

Introduction

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

History of Anti-Asian Racism: 1800s to Present

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

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

COVID-19 Discrimination

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

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

Effects of Racism on Mental Health

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

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

Insidious Racism: Microaggressions and Gaslighting

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

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

Within-Group Differences

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Contributed by: Anna Kiesewetter

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

References

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

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

4 Ibid.

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

6 Nadal et al., 2015

7 Ibid.

8 Yi, 2016

9 Misra & Le, 2020

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

11 Ibid.

12 Misra & Le, 2020

13 Cheng, 2020

14 Misra & Le, 2020

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

16 Ibid.

17 Cheng, 2020

18 Bloomberg Equality 

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

20 Ibid. 

21 Misra & Le, 2020

22 Cheng, 2020

23 Nadal et al., 2015

24 Cheng, 2020

25 Ibid.

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

27 Nadal et al., 2015

28 Ibid. 

29 Ibid.

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

31 Yellow Horse et al., 2021

32 Canady, 2021

33 Nadal et al., 2015

34 Ibid.

35 Ibid. 

36 Cheng, 2020

37 Ibid. 

38 Nadal et al., 2015

39 Misra & Le, 2020

40 Ibid. 

41 Saw et al., 2021

42 Canady, 2021

43 Ibid. 

44 Nadal et al., 2015

45 Misra & Le, 2020