Vol 3

The Role of Gratitude in Improving Mental Health 

Focusing on the Good 

Gratitude has its foundational roots in the humanities, from ancient philosophical studies, to religious conceptualizations, and evolutionary theories. Though gratitude has traditionally been understood and studied in this way, novel insights, questions, and understandings are being developed under the lens of contemporary scientific research today. In the past few decades gratitude has been studied in increasingly precise contexts, from early childhood education, to prosocial behavior in the workplace and potential for chronic disease treatment. Nevertheless, gratitude is still quite difficult to define. Is it an emotion, a virtue or a behavior? The APA gives a general description of gratitude as part of a wider outlook on life that involves noticing and appreciating the positive aspects of life.[1] Though there are many conceptualizations of gratitude, Emmons & McCullough (2003) defined gratitude in two parts: 1) recognizing that one has obtained a positive outcome and 2) recognizing that there is an external source for this positive outcome.[2]

In general, gratitude has been shown to present a plethora of benefits for one’s mental and physical health. It may foster a more positive mood, induce better sleep, and even lower disease markers and inflammation in the body.[3] Additionally, depressive symptoms, substance abuse, anxiety, chronic pain, and risk of disease may be lowered with the implementation of daily gratitude practices.[4] Cultivating feelings of gratitude through practices of mindfulness and daily journaling can fortify relationships with others as well as increase empathy and prosocial behavior. Overall, expressions and practices of gratitude have been extensively studied for its ability to increase well-being, longevity, and happiness. 

The origins of gratitude 

Though gratitude has often been thought of as merely an intuitive emotion or feeling, there have been key developments in various fields that have led to our increased understanding of gratitude and the ways it can be qualitatively and quantitatively measured. 

Evolutionary

The questions surrounding gratitude and its origins can be traced back centuries to evolutionist Darwin. In The Descent of Man (1871), he offers the possibility that humans and other animals share collective emotions, “even the more complex ones such as jealousy, suspicion, emulation, gratitude, and magnanimity.”[5] With this, gratitude may have played a unique role in human social evolution. It has been posited that gratitude is an adaptation for what Robert Trivers first coined as “Reciprocal Altruism” in 1971, or the sequential exchange of costly benefits between non relatives.[6] This is supported by a series of studies by prominent gratitude researchers Mccullough et al. (2008) which explain that a positive feeling of gratitude can alert us to the benefits we’ve received from others and inspire us to show appreciation, which will in turn make others more likely to help us again in the future.[7] The evolutionary advantage is that we become more interconnected and collectively stronger as a society, as strangers become friends and new allyships are created. 

Neurobiological

There have also been more recent studies which incorporate systematic ways of studying and measuring the biological origins of gratitude. In one key fMRI based study by Fox et al. (2015), higher ratings of gratitude correlated with increased brain activity in participants’ anterior cingulate cortex and medial prefrontal cortex. Activity in these regions has been linked to moral cognitive processes, social reward and interpersonal bonding, as well as emotion perception and theory of mind. Previously, it was unknown how the brain generated the range of feelings associated with gratitude; however, this study provides a window into gratitudes origins, as well as its relationship to mental health and resilience.[8]   

Factors that contribute to gratitude

Multiple studies have honed in on certain individual factors that may contribute to increased or decreased expressions of gratitude including personality, cognitive factors, and gender. 

  1. Personality Traits: Recently, Szcześniak et al. (2020) studied the interaction among personality traits, emotional intelligence, and a grateful disposition. They found that both gratitude and emotional intelligence correlated positively and significantly with extraversion, openness to experience, agreeableness, and conscientiousness. Conversely, gratitude and emotional intelligence correlated negatively and significantly with neuroticism.[9]

  2. Cognitive Factors: Certain cognitive factors may also influence the amount of gratitude one feels in a particular situation. Some examples include the perceived intention of the benefactor, the apparent cost to the benefactor, or the value of the gift which vary based on the situation.[10] This differs based on personal experience and background, perception of the situation, and even some larger cultural norms.   

  3. Gender: In particular, Kashdan et al. (2009) hypothesized that women possess an advantage over men in experiencing and benefiting from gratitude. In this comparative study of reaction to gift appraisals, women viewed gratitude expression to be exciting and interesting while men were less likely to feel and express gratitude, made more critical evaluations of gratitude, and derived fewer benefits.[11]   

Along with the numerous individual factors which show variance in either lending to or inhibiting expressions of gratitude, there is also a wider discussion on gratitude as it relates to the complex interplay of religion, culture, and social norms. 

  1. Religion: Gratitude has often been associated with and studied in conjunction with religion and spirituality. Specifically looking at the United States, a study by Krause (2009) found that more frequent church attendance and stronger God-mediated control beliefs are associated with positive changes in gratitude over time.[12] In accordance with these findings, a more generalized study of intergroup differences conducted by Ferenczi et al. (2021) examined religiousness, gratitude, and well-being over time and found that religiousness is linked to higher gratitude and moreover, an increase in gratitude can result in an increase in subjective well-being.[13] 

  2. Culture: Cross cultural research often looks at the difference between individualist and collectivist cultures in the context of behavior, values, practices, and more. Srirangarajan et al. (2020) found evidence that across East Asian and Western cultures, being grateful generally seems to have a similar relationship with a wide variety of psychological variables including but not limited to life-satisfaction, stress and social anxiety, and anger.[14] Another more recent study carried out by Freitas et al. (2022) sampled a participant pool with diverse cultural backgrounds ranging from countries such as China, Brazil, Russia, and Turkey to investigate gratitude as a moral virtue. The main findings indicated that despite the broad array of cultures represented, gratitude as a virtue develops during childhood and is influenced by one's cultural group.[15] 

  3. Parenting Style: As gratitude has been shown to have developmental roots, parenting styles and gratitude in children has also been examined. Obeldobel & Kerns (2021) conducted a literature review that showed how children’s gratitude was higher when parents modeled gratitude, there was a more secure parent–child attachment, and parents employed more supportive, autonomy granting, and warm parenting styles. These findings align with attachment theory, social learning and emotion socialization theories, and the find-remind-and-bind theory.[16] 

Individual Benefits 

Researchers have been interested in gratitude particularly in regard to its potential for improving one’s mental and emotional health for decades. Many key mechanisms and rationales for significant findings have been identified and discussed throughout the existing literature. More recent studies, though, have also begun to incorporate physical health and well-being into experimental design. 

  1. Improving Physical Health: UCLA Health notes that gratitude supports heart health through the improvement of depression symptoms, increased sleep, improved diet and more frequent exercise - which all reduce the risk of heart disease.[17] Additionally, several studies show that a grateful mindset positively affects biomarkers associated with the risk for heart disease. One recent study by Jans-Beken et al. (2021) sought to provide an updated overview of the literature on the connection of gratitude to human health, specifically focusing on experimental study findings. The researchers state that gratitude interventions appear to positively affect a number of cardiovascular and inflammatory parameters, (e.g., a decrease in diastolic blood pressure with daily gratitude journaling) as well as improving sleep quality.[18] In addition, not only has gratitude journaling been shown to lessen depressive symptoms related to chronic illness, but has been shown to lessen inflammatory chronic disease biomarkers such as HbA1c (which is involved in blood sugar control). This is especially important given that high levels of HbA1c have been associated with chronic kidney disease, a number of cancers, and diabetes.[19] 

  2. Improving Well-being: In addition to the evidence of improvements to physical health, many more studies support the idea that a grateful disposition is associated with greater life satisfaction, optimism, subjective well-being, positive affect, and overall happiness.[20] Some mechanisms by which gratitude can positively intervene in one’s life to improve general well-being include counteracting materialism and protecting against burnout. Specifically looking at student culture, Tsang et al. (2014) found that undergraduate students reported less life satisfaction, which could be explained by their lowered levels of gratitude. The study concluded that gratitude played an important mediating role for the negative relationship between materialism and life satisfaction. Grateful people may be less materialistic because they feel more satisfied with their lives - and thus, don’t feel much of a need to acquire new things in order to feel more satisfied.[21] 

  3. Treating Mental Illness: While there is clearly strong evidence for gratitude’s role in improving both mental and physical health, several more studies are concentrating on gratitude interventions for specific psychological challenges and the related mechanisms by which these may elicit significant positive changes. 

    Through various meta-analysis and literature review studies, it is now commonly accepted that gratitude can play a key role in improving depressive symptoms. One recent development, though, comes from a study carried out by Tomczyk et al. (2022), examining gratitude and acceptance of illness for women who were at risk for clinical depression. They identified that women with elevated depressive symptoms who were more grateful (compared to those who were less grateful) were more accepting of their condition, which was related to increased well-being and decreased feelings of depression and anxiety.[22] 

    Gratitude can help promote long-term recovery from substance misuse. In particular, the Narcotic Anonymous (NA) program has adopted gratitude as a key component of recovery and urges members to practice gratitude on a daily basis on their journey toward successful recovery.[23] 

    Several more studies have been conducted under the topic of gratitude’s effect on mitigating stress and anxiety disorders, PTSD, and suicidal ideation. For example, Vieselmeyer et al. (2017) looked at the role that gratitude and resilience played in post-traumatic stress. Particularly relevant to contemporary events and the dramatic increase in the prevalence of community trauma like school shootings, these researchers found that people with high trait gratitude four months following the 2014 Seattle Pacific University shooting showed a stronger relationship between post-traumatic stress and post-traumatic growth, implying that very grateful people are also more resilient and willing to adopt a growth mindset post-trauma.[24] Another study by Li et al. (2015) examined the relationship between suicide ideation and gratitude, finding that the odds of suicidal ideation and suicide attempts were lower among adolescents who scored higher on gratitude, and furthermore, these results were mediated by both prevalence of stressful life events and self-esteem.[25]

    Perhaps one of the most widely studied and supported topics related to mental health and gratitude, though, is its effect on stress and depression. A comprehensive study by Wood et al. 2008 examined the direction of the relationships between trait gratitude, perceived social support, stress, and depression during a life transition. The key findings from this study is that gratitude seems to directly foster social support, and to protect people from stress and depression, which has major implications for clinical interventions.[26] 

  4. Child/Adolescent Health: The Anxiety and Depression Association of America outlines the mental health benefits of gratitude for kids and teens including improving mood, increasing social connection, reducing suicide risk, and improving sleep. Many of the existing studies on child/adolescent gratitude and mental health examine a specific type of intervention (e.g., gratitude journaling) and its longitudinal effects. For example, one study by Tara et al. (2016) sought out to promote positive psychology evidence-based interventions for use in schools. They found that students who completed the gratitude intervention demonstrated enhanced school belonging and gratitude relative to the control group. Thus, a link was established between gratitude, sense of belonging and well-being for school-aged children.[27] The generalizability of this result, however, may not be definitive. In one gratitude article featured in the Journal of Positive Psychology, Hussong et al. (2018) states that children and adolescents often display wider variance in ways of expressing gratitude. In other words, there are different aspects of gratitude moments (i.e., awareness, thoughts, feelings, and actions) and the way that these facets appear in children.[28]

Social Benefits

A major implication of gratitude is in its social benefits. Studies have looked at how gratitude improves relationships between individuals, enhances productivity in the workplace, boosts well-being among students, and stimulates more helping behavior within collective spaces. Especially relevant to the demanding and highly stressful work environment of healthcare since the Covid-19 pandemic, Kersten et al. (2021) was motivated to investigate the effect of gratitude in mitigating and alleviating the effects of burnout in the workplace. They carried out a study, surveying an international sample of employees, showing a clear negative relationship between work-specific gratitude and disengagement, mediated by Interpersonal Helping Behavior (IHB).[29] 

Similarly, other studies have been interested in the relationship between gratitude and prosocial behavior. Prosocial behavior refers to a range of positive behaviors including positive interactions (e.g., friendly play or peaceful conflict resolutions), altruism (e.g., sharing, offering help), and behaviors that reduce stereotypes.[30]

Zhang (2022) was able to identify a positive relationship between gratitude and adolescents’ prosocial behavior as well as further clarify the mechanism by which the effect operates. Two factors in particular were identified as important to cultivating greater prosocial behavior: the sense of meaning in life and self-esteem. Researchers rationalized that the sense of meaning in life generally refers to an awareness of life goals, tasks, and missions, and hence is intertwined with positive physical and mental health, improved mood, and life satisfaction to promote gratitude and prosocial behavior. Moreover, higher self-esteem is recognized as a key factor in adolescents being more attuned to the behavior of others to then form a positive cognition of themself and others.[31]

Gratitude interventions 

It’s clear that gratitude has been conceptualized in many different ways throughout history and utilized within various disciplines and subfields of psychological study. Because of its applicability, gratitude is extremely well-studied and universally accepted as an intervention which can aid mental health struggles and increase life-satisfaction. From maintaining and improving relationships, fostering a more secure sense of self and well-being, as well as being more attuned to others around us, gratitude is an economical, effective, and comprehensive intervention. What are some ways, then, to cultivate a gratitude practice? 

  1. Noting the Positive: One relatively simple practice is “counting blessings” or gratitude journaling (e.g., writing down things one is grateful for either daily or weekly). Another gratitude practice under the same paradigm as journaling is,“mental subtraction.” This activity involves imagining what life would be like if a positive event had not occurred and has been shown to greatly improve mood.[32] 

  2. Mindfulness: According to Ochsner Health, mindfulness is defined as paying attention, on purpose, in the present moment, non-judgmentally. To practice mindfulness is simply to invite yourself to where you already are and to experience and acknowledge that moment without judgment or expectation.[33] Mindfulness has been shown to bring emotional regulation, steady attention, and physical healing over the past few decades with the emergence of modern neuroscience and numerous evidence-based studies.[34] While gratitude is central to happiness, mindfulness can help us cultivate it as it enables us to be present with the feelings and sensations of goodness in our life. Like gratitude, mindfulness is a practice which can be practiced daily and refined over time. 

  3. Acceptance and Commitment Therapy (ACT): This psychotherapeutic intervention integrates the principles of both acceptance and mindfulness in order to increase flexibility in thinking and outcomes. In addition, this therapy hones in on defusion, engagement with emotions, articulation of life values, self-compassion, mindful gratitude, and stepwise movement in accord with one’s life values.[35] An article from positivepsychology.com states “gratitude is about feeling the right way, about the right things, and at the right time. It is inseparably linked with self-discipline and motivation.” Commitment to action and mindful behavior are both tenets of ACT and will also contribute to a stronger, more consistent gratitude practice.[36] 

Though both mindfulness and ACT are well studied and relatively easy to implement in daily life, there are some factors and limitations that have hindered one’s willingness to adopt practices and express gratitude. These include narcissism, gratitude turning into indebtedness or obligation, and cultural differences and cultural contexts which all affect the way we may experience and perceive gratitude. Generally though, gratitude has been posited as social glue which fortifies relationships. At its most effective, gratitude interventions have been shown to elicit positive changes behaviorally, mentally, and physically. It provides a wealth of benefits to those who commit to this principle as a daily practice and lens through which to view life rather than a short term solution. 

If you or someone you know would like to learn more about how to incorporate gratitude in daily life, learn about mindfulness and ACT, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

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

References

1 American Psychological Association. (2015, April 9). A grateful heart is a healthier heart [Press release]. https://www.apa.org/news/press/releases/2015/04/grateful-heart 

2 Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389. https://doi.org/10.1037/0022-3514.84.2.377 

3 APA (2015) 

4 American Psychological Association. (2012, August 5). Growing up grateful gives teens multiple mental health benefits, new research shows [Press release]. https://www.apa.org/news/press/releases/2012/08/health-benefits 

5 Trivers, R. L. (1971). The Evolution of Reciprocal Altruism. The Quarterly Review of Biology, 46(1), 35–57. http://www.jstor.org/stable/2822435 

6 McCullough, M. E., Kimeldorf, M. B., & Cohen, A. D. (2008). An Adaptation for Altruism: The Social Causes, Social Effects, and Social Evolution of Gratitude. Current Directions in Psychological Science, 17(4), 281–285. https://doi.org/10.1111/j.1467-8721.2008.00590.x

7 Suchak, M. (2017, February 1). The Evolution of Gratitude [Review of The Evolution of Gratitude]. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/the_evolution_of_gratitude 

8 Fox, G. R., Kaplan, J., Damasio, H., & Damasio, A. (2015). Neural correlates of gratitude. Frontiers in psychology, 6, 1491. https://doi.org/10.3389/fpsyg.2015.01491 

9 Szcześniak, M., Rodzeń, W., Malinowska, A., & Kroplewski, Z. (2020). Big Five Personality Traits and Gratitude: The Role of Emotional Intelligence. Psychology Research and Behavior Management, Volume 13, 977–988. https://doi.org/10.2147/prbm.s268643 

10 Allen, S. (2018). The Science of Gratitude. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Gratitude-FINAL.pdf?_ga=2.82610261.2142947331.1637096170-1362583773.1634590861 

11 Kashdan, T. B., Mishra, A., Breen, W. E., & Froh, J. J. (2009). Gender Differences in Gratitude: Examining Appraisals, Narratives, the Willingness to Express Emotions, and Changes in Psychological Needs. Journal of Personality, 77(3), 691–730. https://doi.org/10.1111/j.1467-6494.2009.00562.x 

12 Krause, N. (2009). Religious Involvement, Gratitude, and Change in Depressive Symptoms Over Time. International Journal for the Psychology of Religion, 19(3), 155–172. https://doi.org/10.1080/10508610902880204 

13 Ferenczi, A., Tanyi, Z., Mirnics, Z., Kovács, D., Mészáros, V., Hübner, A., & Kövi, Z. (2021). Gratitude, Religiousness and Well-Being. Psychiatria Danubina, 33(Suppl 4), 827–832.https://pubmed.ncbi.nlm.nih.gov/35026809/ 

14 Srirangarajan, T., Oshio, A., Yamaguchi, A., & Akutsu, S. (2020). Cross-Cultural Nomological Network of Gratitude: Findings From Midlife in the United States (MIDUS) and Japan (MIDJA). Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.00571 

15 Freitas, L. B. L., Palhares, F., Cao, H., Liang, Y., Zhou, N., Mokrova, I. L., Lee, S., Payir, A., Kiang, L., Mendonça, S. E., Merçon-Vargas, E. A., O’Brien, L., & Tudge, J. R. H. (2022). How weird is the development of children’s gratitude in the United States? Cross-cultural comparisons. Developmental Psychology. https://doi.org/10.1037/dev0001383 

16 Obeldobel, C. A., & Kerns, K. A. (2021). A literature review of gratitude, parent–child relationships, and well-being in children. Developmental Review, 61, 100948. https://doi.org/10.1016/j.dr.2021.100948 

17 Health benefits of Gratitude. UCLA Health System. (n.d.). https://www.uclahealth.org/news/health-benefits-gratitude   

18 Jans-Beken, L., Jacobs, N., Janssens, M., Peeters, S., Reijnders, J., Lechner, L., & Lataster, J. (2019). Gratitude and health: An updated review. The Journal of Positive Psychology, 15(6), 1–40. https://doi.org/10.1080/17439760.2019.1651888 

19 Allen, S. (2018). The Science of Gratitude. https://ggsc.berkeley.edu/images/uploads/GGSC-JTF_White_Paper-Gratitude-FINAL.pdf?_ga=2.82610261.2142947331.1637096170-1362583773.1634590861 

20 Ibid. 

21 Tsang, J.-A., Carpenter, T. P., Roberts, J. A., Frisch, M. B., & Carlisle, R. D. (2014). Why are materialists less happy? The role of gratitude and need satisfaction in the relationship between materialism and life satisfaction. Personality and Individual Differences, 64, 62–66. https://doi.org/10.1016/j.paid.2014.02.009 

22 Tomczyk, J., Nezlek, J. B., & Krejtz, I. (2022). Gratitude Can Help Women At-Risk for Depression Accept Their Depressive Symptoms, Which Leads to Improved Mental Health. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.878819 

23 Chen, G. (2016). Does gratitude promote recovery from substance misuse? Addiction Research & Theory, 25(2), 121–128. https://doi.org/10.1080/16066359.2016.1212337 

24 Vieselmeyer, J., Holguin, J., & Mezulis, A. (2017). The role of resilience and gratitude in posttraumatic stress and growth following a campus shooting. Psychological Trauma: Theory, Research, Practice, and Policy, 9(1), 62–69. https://doi.org/10.1037/tra0000149 

25 Li, D., Zhang, W., Li, X., Li, N., & Ye, B. (2012). Gratitude and suicidal ideation and suicide attempts among Chinese Adolescents: Direct, mediated, and moderated effects. Journal of Adolescence, 35(1), 55–66. https://doi.org/10.1016/j.adolescence.2011.06.005 

26 Wood, A. M., Maltby, J., Gillett, R., Linley, P. A., & Joseph, S. (2008). The role of gratitude in the development of social support, stress, and depression: Two longitudinal studies. Journal of Research in Personality, 42(4), 854–871. https://doi.org/10.1016/j.jrp.2007.11.003 

27 Diebel, T., Woodcock, C., Cooper, C., & Brignell, C. (2016). Establishing the effectiveness of a gratitude diary intervention on children’s sense of school belonging. Educational and Child Psychology, 33(2), 117–129. https://doi.org/10.53841/bpsecp.2016.33.2.117 

28 Hussong, A. M., Langley, H. A., Thomas, T. E., Coffman, J. L., Halberstadt, A. G., Costanzo, P. R., & Rothenberg, W. A. (2018). Measuring gratitude in children. The Journal of Positive Psychology, 14(5), 563–575. https://doi.org/10.1080/17439760.2018.1497692 

29 Kersten, A., van Woerkom, M., Kooij, D. T. A. M., & Bauwens, R. (2021). Paying Gratitude Forward at Work. Journal of Personnel Psychology. https://doi.org/10.1027/1866-5888/a000296

30 Wright, J. D. (2015). International Encyclopedia of the Social & Behavioral Sciences |ScienceDirect. Sciencedirect.com. https://www.sciencedirect.com/referencework/9780080970875/international-encyclopedia-of-the-social-and-behavioral-sciences 

31 Zhang, D. (2022). The relationship between gratitude and adolescents’ prosocial behavior: A moderated mediation model. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.1024312 

32 Allen (2018) 

33 How Mindfulness and Gratitude Can Improve Your Well-Being | Ochsner Health. Ochsner Health System. https://blog.ochsner.org/articles/giving-thanks-how-mindfulness-and-gratitude-can-improve-your-well-being 

34 Gregoire, C. (2014, March 19). Mind and Body: Jack Kornfield on Gratitude and Mindfulness [Review of Mind and Body: Jack Kornfield on Gratitude and Mindfulness]. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/jack_kornfield_on_gratitude_and_mindfulness 

35 Fradkin, C. (2017). Janina Scarlet: Superhero Therapy: A Hero’s Journey Through Acceptance and Commitment Therapy. Journal of Youth and Adolescence, 46(7), 1629–1632. https://doi.org/10.1007/s10964-017-0658-8 

36 The Neuroscience of Gratitude and How It Affects Anxiety & Grief. (2019, April 9). PositivePsychology.com. https://positivepsychology.com/neuroscience-of-gratitude/#brain-changes 

Understanding Anxious Depression

Double Trouble

Illnesses are considered “comorbid” when a person experiences two or more conditions simultaneously.[1] One of the most common comorbid conditions is anxious depression (i.e., anxiety and depression) where roughly 45-67% of patients with major depressive disorder (MDD) meet criteria for at least one comorbid anxiety disorder and 30-63% of patients with anxiety disorder meet criteria for comorbid MDD.[2] The American Psychiatric Association defines someone as having MDD with anxious distress if they meet the criteria of major depressive disorder plus at least two of five anxiety symptoms (e.g., feeling keyed up or tense, being unusually restless, having trouble concentrating because of worry, having fear that something awful may happen, or feeling that one might lose control of oneself).[3]

How Is Anxious Depression Different?

Anxious depression has a few distinguishing factors from non-anxious depression. A study by Rajkumar R.P. (2022) found that people with comorbid depression and anxiety tend to have an earlier age at the onset of either illness, higher rates of childhood trauma, higher levels of neuroticism, more severe functional impairment, and poorer treatment response.[4] Additionally, people with anxious depression were found to have more frequent episodes of major depression, a higher risk of suicide ideation and previous suicide attempts.[5] Demographically, patients with anxious depression are significantly more likely to be in a primary care setting, female gender, non-single, unemployed, and less educated, according to the NIMH-funded “Sequenced Treatment Alternatives to Relieve Depression” project (STAR*D).[6] Physiologically, a study by Inkster et al. (2011) found that patients with anxious depression had more gray matter in their temporal gyrus compared to those with non-anxious depression.[7]

Reasons For Comorbidity 

Multiple theories explain why the two illnesses co-occur so frequently. One view holds that the two conditions have similar biological mechanisms in the brain, making them more likely to appear together.[8] Another theory states that dysregulation of biological mechanisms (e.g., immune-inflammatory pathways, amygdala, hypothalamic-pituitary-adrenal axis) is the cause.[9] A developmental approach finds that insecure attachment in childhood creates a predisposition to the development of anxious depression.[10] Regarding the environment, theory states that the conditions often present simultaneously when an external stressor or stressors trigger a person.[11] Lastly, there is a diagnostic theory that states since anxiety and depression have many overlapping symptoms (e.g., problems with sleep), people frequently meet the criteria for both diagnoses.[12]

Treatment for Anxious Depression 

The National Alliance on Mental Illness (NAMI) notes that anxious depression is often more challenging to treat due to the illnesses “working together” to cause more intense and persistent symptoms.[13] Thus, individuals may need more specialized treatments to combat their symptoms.[14] For example, if antidepressants prescribed by a psychiatrist improve a person’s mood but not their anxiety, the next step would be to seek a therapist for cognitive behavioral therapy (CBT).[15] 

Various drug therapies are available to help treat anxious depression. An analysis by Choi et al. (2020) revealed that SSRIs were effective in treating anxious depression, benzodiazepines can be used to augment SSRI and treat baseline anxiety, and atypical antipsychotics can be used as augmentation agents for treating major depressive disorder.[16]

If you think you or someone you know may have Anxious Depression, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Maria Karla Bermudez

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

References

1 Salcedo, B. (2018, January 19). The comorbidity of anxiety and depression. NAMI. https://www.nami.org/Blogs/NAMI-Blog/January-2018/The-Comorbidity-of-Anxiety-and-Depression  

2 Choi, K. W., Kim, Y. K., & Jeon, H. J. (2020). Comorbid Anxiety and Depression: Clinical and Conceptual Consideration and Transdiagnostic Treatment. Advances in experimental medicine and biology, 1191, 219–235. https://doi.org/10.1007/978-981-32-9705-0_14

3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

4 Rajkumar R. P. (2022). Comorbid depression and anxiety: Integration of insights from attachment theory and cognitive neuroscience, and their implications for research and treatment. Frontiers in behavioral neuroscience, 16, 1104928. https://doi.org/10.3389/fnbeh.2022.1104928

5 Choi et al., (2020)

6 Fava M, Rush AJ, Alpert JE, Carmin CN, Balasubramani GK, Wisniewski SR, et al. What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension. Can J Psychiatry. 2006;51(13):823–35.

7 Inkster B, Rao AW, Ridler K, Nichols TE, Saemann PG, Auer DP, et al. Structural brain changes in patients with recurrent major depressive disorder presenting with anxiety symptoms. J Neuroimaging. 2011;21(4):375–82

8 Salcedo (2018)

9 Rajkumar (2022)

10 Ibid. 

11 Salcedo (2018)

12 Ibid. 

13 Ibid. 

14 Ibid.

15 Ibid.

16 Choi et al., (2020)

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.

Imposter Syndrome: Mirror, Mirror On the Wall… Am I Worthy of This All?

Drowning in Self-Doubt

 I don’t belong here. I don’t deserve this. I only got this far because I got lucky.  I’m going to fail one day, and then people are going to finally realize what a fraud I am. 

Imposter phenomenon, commonly termed as “Imposter Syndrome,” can drown a person’s mind with self-doubt, fear of failure, and feeling unworthy of their successes. This is a condition that typically affects high-achieving individuals who are unable to internalize their accomplishments, and constantly think of themselves as an “imposter,” or fraud. Instead of attributing their accomplishments to their own efforts and intelligence, they attribute their accomplishments to external factors, such as luck or social support. Despite their objective successes, they focus more heavily on their setbacks, and use those to internally justify the belief that they are a fraud. Currently, there is no formal accepted medical definition for the phenomenon in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) or clinical diagnosis for this phenomenon.[1,2]

Competitive environments naturally bring a sense of self-doubt for many, and this often manifests as a healthy amount of stress that allows an individual to adapt and accomplish their goals appropriately. However, what distinguishes those with imposter phenomenon is excessive self-doubt and worry that significantly interferes with mental health and overall well-being. Some levels of stress can drive success and achievement, but it is important to recognize when the cost of one’s mental health becomes too great. 

Prevalence and Notable Characteristics 

Those who suffer from the imposter phenomenon can range across all ages and genders.[3] However, there it has been found to disproportionately affect students, those in the healthcare field, and minority racial/ethnic groups. High pressure and high stake environments tend to reveal and accentuate imposter phenomena in individuals. Minority groups may be predisposed to the imposter phenomenon due to higher psychological stress in educational and workplace experiences compared to their majority counterparts. In particular, minority individuals may face greater financial stress, racial discrimination, and the pressure to pursue higher education as a first-generation student - all of which contribute to the development of the imposter phenomenon.[4] For instance, minority individuals who work or study in predominantly Caucasian environments may already feel as if they do not belong or deserve a place there, leading them to compensate by working much harder than peers to achieve the same goals.

The idea of self-fulfilling prophecy also comes into play in this situation, as a minority individual who is stereotyped as less intelligent or less capable, and is expected to achieve less, is led to act in a certain way that confirms these expectations despite being perfectly capable to surpass expectations.[5] Children from minority families are also often taught they need to work much harder than their White counterparts to reach the same level of success due to systemic discrimination and racism. This familial and societal pressure to achieve contributes heavily to an individual’s development of imposter phenomena, as self-worth becomes internally contingent on external successes.[6] 

The inability to internalize one's successes is also associated with multiple comorbidities, including depression, anxiety, and other psychological health issues. The phenomenon has been commonly researched in population-based evaluations, but there is an unknown true prevalence due to differences in recruitment strategies for these studies. Bravata et al. (2020) note that the prevalence across studies has ranged from 9%-82%.[7] Common characteristics that may be present in those who suffer from imposter phenomenon include:[8]

  • Perfectionism

  • Super-heroism (e.g., the need to be the best)

  • Atychiphobia (e.g., fear of failure)  

  • Denial of competence

  • Achievemephobia (e.g., fear of success)

  • Burnout

  • Low self-esteem 

  • Excessive comparison to peers 

  • Maladaptive personality

To evaluate for imposter phenomenon, the Clance Imposter Phenomenon Scale is highly utilized as a diagnostic tool. The tool contains 20 Likert-scale agree/disagree questions, which have not been externally validated.[9] Examples of some of these questions include:[10]

  • “I can give the impression that I’m more competent than I really am.”

  • “It’s hard for me to accept compliments or praise about my intelligence or accomplishments.”

  • “I’m often afraid that I may fail at a new assignment or undertaking even though I generally do well at what I attempt.”

The Imposter Cycle 

The classic cycle that an individual with imposter phenomenon faces starts with an assignment, duty, obstacle, or another task which requires reaching a certain level of achievement. The individual will then choose one of two paths: over-preparation or procrastination. Those who over-prepare will feel as if they have to work excessively hard, especially harder than those around them, to achieve that goal. Those who procrastinate will feel as if they are an imposter because they are rushed in preparation, and worry that their rushed efforts portray them as a fraud. After the task is completed, and the goal is achieved, they will experience a short sense of success, which is quickly diminished by overwhelming feelings of fear, anxiety, and fraudulence that leads them to repeat the cycle when presented with a new task.[11] This cycle may end up sabotaging their own success, creating an obsession over any small mistake, and working intensely hard to prove they are not a fraud to themselves.[12]

Conquering The Voice in Your Head

Building resilience and overcoming imposter feelings requires active efforts on both the individual’s part, and the environment in which they work or study. For an individual, the medical and behavioral health treatments involve careful evaluation to determine how to target these feelings. Such treatments can include:[13]

Individuals must also actively practice gratitude strategies to appreciate their own achievements and work ethic. One way to start is by learning about imposter feelings, and where these negative feelings can derive from. Then, the practice of self-reflection can be used to identify the imposter-related negative feelings. Sharing these feelings with a counselor or therapist, or even trusted friends and family, can help a person gain a better appreciation for their achievements and abilities. Additionally, finding others that share these feelings can bring more solace and safety in one's workplace or academic environment, as building a support network can reduce isolation and loneliness while facing these negative feelings. It is also important to ask for help when needed, especially since many people suffering from imposter feelings believe they are completely alone in their pursuits, and in order to avoid fraudulent feelings, they steer clear from external support.[14] 

Genuinely celebrating each success, instead of simply brushing them off and moving ahead, can help one practice gratitude and internalize their successes, breaking down barriers of self-doubt in the future. Instead of focusing on perfectionism, and aiming for the achievement, take the time to appreciate any progress and efforts to get there. Track your success and remind yourself of your abilities when self-doubt becomes overwhelming. This serves as a way to increase your internal validation.[15] Practice mindfulness, and build a sense of self-worth outside of academic or professional accomplishments. Positive qualities about character and personality are also triumphs to be celebrated and appreciated. Doing so can help build self-compassion, and lean away from basing one's self-worth on how high a test score was achieved or how big of a promotion was obtained. Take time to learn from failures and mistakes, but also remember that behind every large success there is a series of setbacks.[16] Making an organized plan for success is another way to avoid overwhelming yourself and more strategically reaching your goals, one step at a time. Managing anxious imposter feelings can be done by breaking down a larger goal into smaller attainable goals/tasks that allow you to practice consistency in your work and confidence in yourself.[17]

Institutions can also actively reduce imposter feelings for their employees or students by generating a more inclusive and diverse community. This will help encourage minorities to feel more encouraged and comfortable in their environment, leading them to feel more confident with their successes and attempts for success.[18]

The imposter phenomenon can overwhelm a person’s mind and body. Developing healthy coping mechanisms is crucial to maintain a positive psychological state of well-being. After acknowledging one's feelings and practicing self-reflection, a person may make efforts to change their lifestyle to accommodate for such high levels of stress and anxiety due to impostor feelings. This may involve setting new reasonable goals or expectations, rather than aiming for the highest achievement at all times. Unreasonably high goals can hurt chances of success, leaving one feeling more discouraged. Instead, build a momentum for success by making reasonable and attainable goals, and build off of these goals more and more as they continue to be reached. In other words, take it one step at a time. One may choose to find a mentor that can guide them towards their goals, eliminating the feeling of isolation that frequently pairs with imposter feelings. Teaching others what you have learned through your accomplishments can also help internalize your own successes, building confidence in yourself while simultaneously encouraging others.[19]

If one has been feeling increasing symptoms of the imposter phenomenon, and it is impacting daily life and overall mental or physical health, it is recommended to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance on reducing anxiety and impostor feelings.

Contributed by: Ananya Udyaver

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

References

1 Bravata, D. M., Madhusudhan, D. K., Boroff, M., & Cokley, K. O. (2020, August 24). Commentary: Prevalence, Predictors, and Treatment of Imposter Syndrome: A Systematic Review. Journal of Mental Health and Clinical Psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7174434/ 

2 Huecker, M. R., Shreffler, J., McKeny, P. T., & Davis, D. (2023, April 9). Imposter Phenomenon - statpearls - NCBI Bookshelf. Imposter Phenomenon. https://www.ncbi.nlm.nih.gov/books/NBK585058/  

3 Ibid.

4 Ibid.

5 Palmer, C. (2021, June 1). How to overcome impostor phenomenon. Monitor on Psychology, 52(4). https://www.apa.org/monitor/2021/06/cover-impostor-phenomenon 

6 Weir, K. (n.d.). Feel like a fraud?. American Psychological Association. https://www.apa.org/gradpsych/2013/11/fraud  

7 Bravata, et al. (2020) 

8 Huecker, et al. (2023)

9 Ibid.

10 Clance, P. R., & O'Toole, M. A. (1987). The Imposter Phenomenon: An internal barrier to empowerment and achievement. Women & Therapy, 6(3), 51–64. https://doi.org/10.1300/J015V06N03_05 

11 Ibid. 

12 Munley, K. (2020, December 2). Expert or poser? debunking the psychology behind Imposter Syndrome. ScIU. https://blogs.iu.edu/sciu/2020/11/21/expert-or-poser/  

13 Huecker, et al. (2023)

14 Weir, K. (n.d.). Feel like a fraud?. American Psychological Association. https://www.apa.org/gradpsych/2013/11/fraud  

15 Jaqua, E. E., Nguyen, V., Park, S., & Hanna, M. (2021). Coping With Impostor Syndrome. Family practice management, 28(3), 40. https://pubmed.ncbi.nlm.nih.gov/33973753/ 

16 Palmer (2021) 

17 Munley (2020)

18 Eruteya, K. (2022, January 5). You’re not an imposter. you’re actually pretty amazing. Harvard Business Review. https://hbr.org/2022/01/youre-not-an-imposter-youre-actually-pretty-amazing   

19 Jaqua, et al. (2021) 

Wounds Outside of Combat: Sexual Trauma in the Military

Sexual Violence: A Prevailing Issue

Sexual violence persists within all branches of the armed forces and in recent years, reports of sexual assault and harassment have garnered national attention. Sexual harassment and assault are also more prevalent within the military than in the majority of civilian organizations. While the armed forces progress in addressing this challenging issue, understanding sexual violence in a military context offers a lesser-known perspective on sexual trauma’s challenges.

In 2020, Fort Hood specialist Vanessa Guillen was assaulted and killed by a fellow soldier within her chain-of-command. This event was one of many that year that increased visibility on issues in the armed forces’ efforts against sexual violation. Even before Vanessa Guillen’s murder, the military was under pressure to improve their culture and overcome rampant reports of sexual assault. In 2004, a Department of Defense (DOD) task force aiming to provide resources to sexual assault survivors made recommendations for systematic changes to better support soldiers who experience sexual violence.[1] Those recommendations included developing a central point of accountability and a unified response system.[2] A year later, the military acknowledged that mandating commanders to be notified of crimes of sexual violence was a deterrent to soldiers who feared retaliation from their supervisors, peers, assailant (all of whom have the potential to be the same person) after reporting and removed this requirement.[3] The task force concluded their investigation by creating training on Sexual Assault Prevention and Response (SAPR) that has been led by the SAPR office, headquartered at the Pentagon. In the subsequent decades, the DOD and Department of Veteran Affairs have continued implemented several policies to improve treatment, clarify reporting procedures and provide long-term support to sexual assault victims.[4]

In 2022, public backlash over the discovery of murdered soldiers at Fort Cavazos, Texas spurred the military to add sexual harassment as a crime under the Uniform Code of Military Justice (UCMJ).[5] Still, despite decades of efforts against sexual violence, in the last two fiscal years research conducted by the Department of Veterans’ Affairs reported an increase of soldiers who filed unrestricted reports after being sexual assaulted and/or harassed. According to a fiscal year 2022 report submitted by the Pentagon, the rate of sexual assaults had risen 1% from the previous year.[6] Officials maintain that the increase of sexual assault reports is a positive step toward addressing the cultural problem because it implies that soldiers have less of a fear of retaliation or ostracization.[7] However, for service members, their families and future recruits, this increase potentially signals that the military is still searching for an enduring solution to the corrosive issue of sexual violence.[8] 

Defining Military Sexual Trauma (MST)

Military sexual trauma (MST) is a term used by the armed forces and Veterans Affairs (VA) to refer to sexual harassment and/or sexual assault that occurs in the military. According to the Department of Veterans Affairs, MST is specifically defined as: physical assault of a sexual nature, battery of a sexual nature, or sexual harassment (unsolicited verbal or physical contact of a sexual nature which is threatening in character) which occurred while the former member of the Armed Forces was serving on duty, regardless of duty status or line of duty determination.[9] Unlike other organizations, the VA extends the definition of MST to sexual harassment to encompass both physical and verbal instances of sexual encounters to which service members did not consent.

Specific examples include, but are not limited to:[10]

  • Being coerced or pressured into any kind of sexual activity (with the potential fear of negative repercussions if an individual does not consent, or promises any kind of advantage if they engage) 

  • Any form of physical contact or action without consent, including when a person is in a state that renders them completely incapable of communicating (e.g., sleeping, sick, intoxicated)

  • Being forced to engage in sexual activity through physical harm such as slapping, kicking, punching or assault with any form of a weapon

  • Being touched or grabbed in a sexual way during hazing or training

  • Any unwanted comments about a person’s body or sexual activities that they perceive to violate a personal boundary

  • Sexual advances that are spoken, gestured, sent through the phone or online

Like the DOD, the VA acknowledges sexual harassment with similar gravity to sexual assault, implementing resources such a hotline, victim advocates, and VA police for any individual who seeks resources or wishes to file a report.[11]

Common Symptoms Post-Trauma

After a sexually traumatizing event, veterans experience elevated rates of mental disorders, physical ailments, and difficulty building interpersonal relationships.

Specific impacts on health include:

Mental  

MST survivors have a high lifetime rate of post-traumatic stress disorder (PTSD) for both men at women, at 65% and 45% respectively.[12] Veterans who report MST and have PTSD are also likely to have comorbid major depression, anxiety, eating disorders, and substance use disorders. MST also exacerbates pre-existing mental health conditions, worsening the symptoms of conditions prior to the trauma-inducing event.[13]

Physical

Sexual difficulties, chronic pain and/or gastrointestinal disease are common physical health problems for service members recovering from sexual assault and/or harassment. [14] Survivors’ cognitive function is also impaired - many recovering service members report reduced ability to pay attention, concentrate and remember details.[15]

Interpersonal Relationships  

In some cases, veterans who experienced sexual abuse harbor trust issues and have problems engaging in social activities and intimacy. Struggling to progress out of isolation, many survivors also report difficulties finding or maintaining work after their military service.[16]

Prevalence of MST in Different Groups

Regardless of a person’s socioeconomic gender, ethnicity or identity there is still a chance that they are vulnerable to predatory behavior and sexual violence. Surveys indicate that 1% of active duty men and nearly 5% of active duty women are victimized in any given 12-month period.[17] In another study conducted in 2016, researchers from the University of Mary Washington compiled statistics on veterans reporting military sexual trauma across the following databases: PsycINFO, PubMed, and PILOTS.[18] The results revealed that 15.7% of current military personnel and veterans report MST when the measure includes both harassment and assault.[19] Additionally, 13.9% report MST when the measure assesses only assault and 31.2% report MST when the measure assesses only harassment.[20] Across all military branches MST was significantly higher among veterans who reported using VA healthcare services.[21]

Women

Women are significantly more likely to experience and report MST than their male counterparts.[22] Roughly one-in-three women veterans have told their VA health care provider they experienced sexual harassment or assault while in the military.[23] Women with MST also have higher rates of PTSD than those with other traumas: 60% and 43%, respectfully.[24]

Men

Contrary to common misconceptions, men are also victims of sexual violence. Male service members have a 3.9% likelihood of reporting abuse when the measure includes both harassment and assault, and a 1.9% likelihood when the measure assesses only assault. Fearing judgment and alienation, male victims underreport sexual assault and/or harasment; Rossellini et al. (2017) note the true number of such men might exceed that of women, as men have a much lower rate of reporting to authorities than their female counterparts.[25] 

Ethnic Minorities

Ethnic minorities (particularly women of color) experience MST at greater levels than their Caucasian counterparts, with research conducted in 2023 at Washington University in St. Louis revealing that 21% of ethnic minority female veterans compared with 1% of ethnic minority male veterans have experienced MST.[26] Black women are also the most-likely to delay disclosure of MST.[27]

LGBTQ+

Research at Washington University in St. Louis also discovered that while non-LGBTQ service members report MST at a rate of 14%, those identifying as sexual minorities report MST at nearly twice the rate at 26%.[28] Experiencing the greatest rate of sexual harassment/assault, nearly 1-in-3 transgender service members (30%) report MST. 

Other Demographics

In a 2022 study conducted at Pennsylvania University, researchers found that those who experienced adversity or trauma during childhood were more likely to experience Military Sexual Trauma (MST) during their service (Auman-Bauer 2022).[29]

Other factors that exacerbate a person’s potential to be sexually assaulted or harassed in the military include:

  • Age/young adults

  • Having a low level of education

  • Being unmarried

  • Having a lower rank

  • Being within their first contract of recently entered service         

Post-Trauma Care & Recovery

Peer support has emerged as a form of treatment that mitigates symptoms of loneliness and isolation, and is a common example of clinical care and support during an MST survivor’s journey through recovery. Organizations like the Women Veterans Network (WoVeN) and Veterans Sisters are examples of peer support with the mission to increase community and connection and provide resources for women veterans.

Penn State University researchers who identified the connection between MST and previous combat experience and childhood trauma propose screening service members prior to leaving the military in order to try to determine how to best treat them.[30] Under this proposal, the military hands the patients’ information off to the VA, to then provide specific trauma-informed care to service members who have experienced trauma as they transition out of active-duty.[31]

The mobile app Beyond MST provides self-help tips, assessments, and skills-based tools to support the health and well-being of MST survivors. Designed by the VA, this app comes at no cost, does not disclose a person’s personal information, and helps service members regain hope and heal.[32]

Post-MST Psychotherapy

The Veterans Affairs Office of Research and Development conducted a study in 2006 to determine which treatment methods were most effective in treating post-MST symptoms.[33] As the researchers determined, treating sexual violence in military settings is unique and departs from clinical approaches to civilian sexual trauma for two reasons: veterans with MST are likely violated by trusted military personnel and victims are often without access to immediate treatment.[34] Although MST treatments continue to evolve, effective therapies include Cognitive Behavorial Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR), and narrative therapy. In certain instances, psychiatrists also prescribe anti-anxiety medication and/or anti-depressants.[35]

Brothers in Arms? Regaining Trust in the Military

As the armed forces continue to work to appeal to a younger generation, the slow improvement with addressing sexual assault has the potential to impact the number and diversity of recruits. In 2021 Secretary of Defense General (Gen.) Lloyd Austin established the Independent Review Commission on Sexual Assault in the Military to improve efforts in accountability, prevention, and victim care.[36] After receiving the commission’s results, Gen. Austin accepted every proposed policy change, and later remarked, “These investments are pivotal to restore the trust of our service members, as well as those considering military service.”[37] The accepted changes include increasing workers within the sexual assault response workforce, including victim advocates and sexual assault response coordinators.

Still, the military has added work to do before it fully controls the sexual assault and harassment within its ranks. In 2013, the investigative documentary The Invisible War earned critical and commercial success for shedding light on the pervasive issue of sexual assault in every military branch.[38] Featuring stories from over 25 soldiers, the documentary was groundbreaking in its final message: a female soldier in combat zones is more likely to be raped by a fellow soldier than killed by enemy fire.[39]

Although the film was made over a decade ago, this statistic still stands, and the victims of sexual assault carry symptoms of PTSD, agoraphobia, and depression - much like their counterparts who endured combat. According to the Rape, Abuse and Incest National Network, these destructive long-term physical, psychological, and social effects of sexual violence on the victims cannot be underestimated, and as veterans integrate into the civilian world, mental illnesses put them at higher risks of homelessness, unemployment, and suicide.[40] Leaders in and outside of the military continue to gain awareness into the emotional and mental impacts of sexual violence. However, the military must not only attempt to eliminate sexual violence by developing new policies and regulations - it must also address the intangible part of its culture that has allowed this violence to persist.

Contributed by: Kate Campbell

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

References

1 Department of Defense. Task Force Report on Care for Victims of Sexual Assault. National Center on Domestic and Sexual Violence Website. http://www.ncdsv.org/images/DOD_TaskForceReportOnCareForVictimsOfSexualAssault_4-2004.pdf

2 National Resource Center on Domestic Violence (NRCDV). (2021). Sexual violence in the military. NRCDV Website. https://vawnet.org/sc/sexual-violence-military-0

3 Ibid.

4 Ibid.

5 Chappell, B. (2022, January 27). Vanessa Guillen’s murder led the U.S. to deem military sexual harassment a crime. National Public Radio Website. https://www.npr.org/2022/01/27/1076143481/vanessa-guillen-murder-military-sexual-harassment-crime

6 Ware, D. (2023, April 28). Reports of sexual assaults increased in the Navy, Air Force, and Marines in 2022; Army saw a decline. American Legion Website. https://www.legion.org/news/258848/reports-sexual-assaults-increased-navy-air-force-and-marines-2022-army-saw-decline#:~:text=There%20were%208%2C942%20reports%20of,slight%20increase%20from%20last%20year

7 Ibid.

8 U.S. Department of Defense. (2022, September 2). DOD takes measures as sexual assault annual report numbers released. U.S. Department of Defense Website.https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

9  U.S. Congress. (2004). United States Code: Uniform Code of Military Justice, 38 USC 1720D: Counseling and treatment for sexual trauma. Retrieved from the Library of Congress, https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title38-section1720D&num=0&edition=prelim

10 U.S. Department of Veterans Affairs. (2023, May 18). Military Sexual Trauma. U.S. Department of Veterans Affairs Website. https://www.mentalhealth.va.gov/msthome/index.asp

11 U.S. Department of Veterans Affairs. (2022, December 12). VA’s Anti-Harassment and Anti-Sexual Assault Policy. U.S. Department of Affairs Website. https://www.va.gov/stop-harassment/policy/

12 Disabled American Veterans (DAV). (2023). What is Military Sexual Trauma? DAV Website. https://www.dav.org/get-help-now/veteran-topics-resources/military-sexual-trauma-mst/

13 Ibid.

14 Ibid. 

15 Ibid.

16 Ibid.

17 Bicksler, B., Farris, C., Ghosh-Dastidar, B., Jaycox, L.H., Kilpatrick, D., Kistler, S., Street, A., Tanielian, T., Williams, K.H. (2014).Sexual Assault and Sexual Harassment in the U.S. Military. Rand Corporation Website. https://www.rand.org/pubs/research_reports/RR870z2-1.html

18 Wilson L. C. (2018). The Prevalence of Military Sexual Trauma: A Meta-Analysis. Trauma, violence & abuse, 19(5), 584–597. https://doi.org/10.1177/1524838016683459

19 Ibid.

20 Ibid.

21 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

22 Wilson (2018)

23 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

24 Yaeger, D., Himmelfarb, N., Cammack, A., & Mintz, J. (2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal of general internal medicine, 21 Suppl 3(Suppl 3), S65–S69. https://doi.org/10.1111/j.1525-1497.2006.00377.x

25 Rosellini, A. J., Street, A. E., Ursano, R. J., Chiu, W. T., Heeringa, S. G., Monahan, J., Naifeh, J. A., Petukhova, M. V., Reis, B. Y., Sampson, N. A., Bliese, P. D., Stein, M. B., Zaslavsky, A. M., & Kessler, R. C. (2017). Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army. American journal of public health, 107(5), 732–739. https://doi.org/10.2105/AJPH.2017.303693

26 Barth, S. K., Kimerling, R. E., Pavao, J., McCutcheon, S. J., Batten, S. V., Dursa, E., Peterson, M. R., & Schneiderman, A. I. (2016). Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. American journal of preventive medicine, 50(1), 77–86. https://doi.org/10.1016/j.amepre.2015.06.012

27 Goldbach, J. T., Schrager, S. M., Mamey, M. R., Klemmer, C., Holloway, I. W., & Castro, C. A. (2023). Development and Validation of the Military Minority Stress Scale. International journal of environmental research and public health, 20(12), 6184. https://doi.org/10.3390/ijerph20126184

28 Ibid.

29 Ibid.

30 Bauer, K.A. (2022, August 24). Military sexual trauma more likely among veterans with prior adversity, trauma. Social Science Research Institute at the University of Pennsylvania Website. https://www.psu.edu/news/social-science-research-institute/story/military-sexual-trauma-more-likely-among-veterans-prior/

31 Ibid.

32 Galovski, T. E., Street, A. E., Creech, S., Lehavot, K., Kelly, U. A., & Yano, E. M. (2022). State of the Knowledge of VA Military Sexual Trauma Research. Journal of general internal medicine, 37(Suppl 3), 825–832. https://doi.org/10.1007/s11606-022-07580-8

33 Goldbach et. al (2023)

34 Suris, A.M. (2006). Treatment for veterans with military sexual trauma. VA Office of Research and Development. https://classic.clinicaltrials.gov/ct2/show/NCT00371644#contactlocation

35 Ibid.

36 U.S. Department of Defense. (2022, September 2). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. Department of Defense Website. https://www.defense.gov/News/News-Stories/Article/Article/3148495/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

37 United States Air Force. (2022, September 5). DOD Takes Proactive Measures as Sexual Assault Annual Report Numbers Released. United States Air Force Website. https://www.aflcmc.af.mil/NEWS/Article-Display/Article/3149016/dod-takes-proactive-measures-as-sexual-assault-annual-report-numbers-released/

38 Huval, R.I. (2013, May 10). Sen Kristen Gillibrand credits The Invisible War with shaping new bill. Public Broadcasting Station Website. https://www.pbs.org/independentlens/blog/sen-gillibrand-credits-the-invisible-war-in-shaping-new-bill/

39 Ibid.

40 Thurston, A. (2022, November 9). Why veterans remain at greater risk of homelessness. The Brink, pioneering research from Boston University Website. https://www.bu.edu/articles/2022/why-veterans-remain-at-greater-risk-of-homelessness/

"I Don’t Remember Last Semester" - Examining the Normalcy of Blacking Out On College Campuses

A Truth of College Life

College life is often associated with memorable experiences and substance experimentation. However, an alarming phenomenon has taken root on college campuses: "blacking out." Miller et al. (2018) note that 49% of college students who drink experience alcohol-induced blackouts.[1] In a society where excessive alcohol consumption has become commonplace among college students, it is crucial to explore the associated underlying influences and mental health issues, in addition to spreading support to those affected.

Understanding Blacking Out

Blacking out refers to a state of temporary amnesia triggered by excessive alcohol consumption, in which memories from experiences of heavy alcohol consumption cannot be recovered. Binge drinking (i.e., excessive drinking in short periods of time) is as prevalent as alcohol-induced blackout experiences among college students.[2] This indicates the link between college cultures of normalized, excessive drinking and frequent blackout experiences. In her memoir, “Blackout: Remembering the Things I Drank to Forget,” University of Texas alumni Sarah Hepola shares that through her research and interactions with current college students, she discovered that blacking out is now considered more casual than it once was 40 years ago, when she was attending UT.[3] In many college cultures, blacking out is often perceived as an inevitable rite of passage, trivializing its potential dangers as it is employed through peer pressure or initiations, particularly in fraternities and sororities.[4]

The National Institute on Alcohol Abuse and Alcoholism (NIAA) notes that blackouts can be separated into two categories:[5]

1. Fragmentary Blackouts - Fragmented memories from events during alcohol consumption exist, but without the ability to connect them.

2. Complete Amnesia - Memories from events during alcohol consumption cannot be recovered.

It is crucial to differentiate between occasional alcohol-related memory lapses and chronic blackouts, which might indicate underlying alcohol use disorder (AUD). Identifying these distinctions early-on can significantly impact an individual's mental well-being and prevent future difficulties with alcohol addiction. It is also important to distinguish blacking out from passing out following alcohol consumption. While “passing out” is the loss of consciousness or falling asleep from excessive drinking, “blacking out” refers to the loss of memories and the inability to create new memories while in a state of excessive alcohol consumption.[6] While a person can blackout and subsequently pass out, it’s also possible to blackout while still remaining completely awake (but unaware).

Your Brain When You Blackout

The amount of alcohol that one's body can withstand depends on blood alcohol concentrations (BACs). The NIAA reports that BACs of about 0.16 percent (about twice the legal driving limit) and above can induce blackouts.[7] However, this value can vary and become lower among:[8]

  • Those who consume anti-anxiety medications 

  • Those who consume common anti-inflammatories (e.g., Advil/ibuprofen)

  • Those who consume alcohol more frequently (indicative of a tolerance)

Many other substances like opioids and antidepressants, in combination with alcohol, can lessen the BAC threshold as well, increasing risks related to these drugs or medications (e.g., overdose or liver failure).[9]

This excessive amount of alcohol results in the temporary block of the transfer of memories, or memory consolidation, from short-term to long-term memory storage via brain structures including the hippocampus.[10,11] Specifically, blackouts lead to anterograde amnesia: the prevention of the formation or storage of new memories.[12] Banerjee (2014) notes that alcohol’s interaction with neurons in the brain leads to the enhancement of inhibitory neurotransmitters and pathways like GABA while lowering the function of excitatory neurotransmitters like glutamate.[13] Such processes lead to heavy intoxication symptoms of poor motor function, altered reward systems, slurred speech, impulsive behavior and poor memory.

From a long-term lens, Nunes et al. (2019) found that frequent blackouts and binge drinking can lead to degenerative and functional deficit trends in the brain through hippocampal and frontal brain damage.[14] Additionally, going to sleep intoxicated shortens the REM (Rapid Eye Movement) phase of sleep [15] which Peever & Fuller (2016) found is responsible for consolidating memories and information in the brain from that day.[16] Exacerbating the issue, this loss of REM sleep may contribute to both short-term and long-term memory/cognitive issues.[17]

Mental Health Consequences 

In addition to impacting cognitive functioning, blackouts inflict significant effects on one’s emotional well-being. Miller et al. (2020) found that in heavy-drinking college students, blackouts were related to increased symptoms of depression.[18] Further, students who experience blackouts may already struggle with anxiety and depression, and abuse alcohol as a coping tool. For example, alcohol can often be employed as a social anxiety “buffer”, as alcohol alleviates behavioral inhibitions.[19] In a survey of 772 college students by White et al. (2002), increased frequencies of blackouts were associated with lower grades, increased heavy drinking and increased frequencies of high-risk behaviors like vandalism.[20] College student blackouts can also impact many aspects of a young person's life including academics, physical health, depression and anxiety risk, memory and cognition, sexual assault risk, and even suicide.[21] 

Pertaining to the college cultures that promote the normalization of blackouts, Greek Life subpopulations are of particular interest. Turrisi et al. (2006) note that these organizations are linked to heavier alcohol consumption.[22] Further, Estaban et al. (2018) found that male fraternity engagement predicted high levels of binge drinking and other drug use in young adulthood as 45% of participants experienced alcohol use disorder (AUD) by age 35.[23] These rates were significantly higher when compared to non-fraternity-associated adults.[24] Additionally, as Cara Rosenbloom in The Washington Post (2019) remarks, eating disorder rates are increased for these college subgroups, and the term “drunkorexia” (purging before excessive alcohol consumption) has arisen on campuses.[25] This phenomenon has created tendencies of heavy and high-risk drinking to replace normal eating, particularly among women struggling with body image.[26] The lack of food in one’s system when consuming alcohol makes binge drinking even more dangerous, as it increases the rate of intoxication.

Shedding the Light on Blacking Out

Due to societal stigmas surrounding mental health, many students hesitate to seek help or support. Wombacher et al. (2019) add that most college students rationalize frequently blacking out while completely acknowledging that the habits are unhealthy.[27] It is crucial to normalize help-seeking behavior and offer accessible resources to those facing alcohol-related issues and potential mental health concerns. By promoting responsible drinking and educating students about the risks, universities can foster a safer environment conducive to positive mental health, both relevant to long and short-term life. Integrating mental health support into college curricula and readily available campus resources empowers students to address their concerns proactively.

Harm reduction approaches may target the engrained social norms on college campuses. In this way, resources may be provided to reduce high rates of negative consequences such as emergency room visits due to alcohol poisoning, anxiety and depression and dangerous behavior. Such educational approaches may spread information about:

  • Substances to avoid combining with alcohol

  • Ways to be mindful when partaking in alcohol consumption

  • Safe sexual practices like consent

  • Awareness to avoid situations of peer pressure

  • Accessibility to counseling and medical care

  • Bystander awareness training 

Additionally, student accessibility to forms of psychotherapy would lead to beneficial effects for students struggling with alcohol use. For example, Ehman & Gross (2019) found that Acceptance and Commitment Therapy (ACT), a modality used to focus on awareness of mental states and thoughts, in addition to Motivational Interviewing (MI), lead to reductions in alcohol consumption and less heavy drinking in college students.[28]

Blacking out might be perceived by many as an “ordinary part of college life”, but its implications on physical, mental and cognitive health require urgent attention. By raising awareness about the normalcy and consequences of blacking out, it is possible to dismantle the harmful aspects of social cultures that perpetuate this behavior. 

If one is experiencing excessive alcohol use, binge drinking, addiction, or blackouts that impair well-being and/or daily life, 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 Miller, M. B., Merrill, J. E., DiBello, A. M., & Carey, K. B. (2018). Distinctions in Alcohol-Induced Memory Impairment: A Mixed Methods Study of En Bloc Versus Fragmentary Blackouts. Alcoholism, clinical and experimental research, 42(10), 2000–2010. https://doi.org/10.1111/acer.13850 

2 Juergens, J. (2023, April 17). Binge Drinking. AddictionCenter. https://www.addictioncenter.com/alcohol/binge-drinking/ 

3 Walsh, K. (2015, November 25). UT Unspoken: Students Reflect on Blackout Drinking Culture. The Daily Texan. https://thedailytexan.com/2015/11/25/ut-unspoken-students-reflect-on-blackout-drinking-culture/

4 Ibid. 

5 National Institute on Alcohol Abuse and Alcoholism. (2023 February). Alcohol’s Effects on Health: Research-Based Information on Drinking and its Impact. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/interrupted-memories-alcohol-induced-blackouts

6 Ibid.

7 Ibid. 

8 Ibid.

9 National Institute on Alcohol Abuse and Alcoholism. (2022, May 6). The Healthcare Professional’s Core Resource on Alcohol: Alcohol-Medication Interactions. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-medication-interactions-potentially-dangerous-mixes#:~:text=Nonsteroidal%20anti%2Dinflammatory%20drugs%20(NSAIDs,alcohol%20significantly%20increases%20the%20risk. 

10 Wetherill, R. R., & Fromme, K. (2016). Alcohol-Induced Blackouts: A Review of Recent Clinical Research with Practical Implications and Recommendations for Future Studies. Alcoholism, clinical and experimental research, 40(5), 922–935. https://doi.org/10.1111/acer.13051 

11 National Institute on Alcohol Abuse and Alcoholism

12 American Addiction Centers. (2023, July 12). Blackout Drunk: Signs, Causes, and Dangers of Blackout Drinking. https://americanaddictioncenters.org/alcoholism-treatment/blackout 

13 Banerjee N. (2014). Neurotransmitters in alcoholism: A review of neurobiological and genetic studies. Indian journal of human genetics, 20(1), 20–31. https://doi.org/10.4103/0971-6866.132750

14 Nunes, P. T., Kipp, B. T., Reitz, N. L., & Savage, L. M. (2019). Aging with alcohol-related brain damage: Critical brain circuits associated with cognitive dysfunction. International review of neurobiology, 148, 101–168. https://doi.org/10.1016/bs.irn.2019.09.002

15 Brower K. J. (2001). Alcohol's effects on sleep in alcoholics. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 25(2), 110–125.

16 Peever, J., & Fuller, P. M. (2016). Neuroscience: A Distributed Neural Network Controls REM Sleep. Current biology : CB, 26(1), R34–R35. https://doi.org/10.1016/j.cub.2015.11.011

17 Brower (2001)

18 Miller, M. B., DiBello, A. M., Merrill, J. E., Neighbors, C., & Carey, K. B. (2020). The role of alcohol-induced blackouts in symptoms of depression among young adults. Drug and alcohol dependence, 211, 108027. https://doi.org/10.1016/j.drugalcdep.2020.108027 

19 Locco, A. (2021, March 15). Alcohol and Blacking Out. Resurgence Behavioral Health. https://resurgencebehavioralhealth.com/blog/alcohol-blacking-out/ 

20 White, A. M., Jamieson-Drake, D. W., & Swartzwelder, H. S. (2002). Prevalence and correlates of alcohol-induced blackouts among college students: results of an e-mail survey. Journal of American college health : J of ACH, 51(3), 117–131. https://doi.org/10.1080/07448480209596339 

21 Juergens (2023)

22 Turrisi, R., Mallett, K. A., Mastroleo, N. R., & Larimer, M. E. (2006). Heavy Drinking in College Students: Who Is at Risk and What Is Being Done About It? The Journal of general psychology, 133(4), 401. https://doi.org/10.3200/GENP.133.4.401-420 

23 Esteban, S., Veliz, P., & Schulenberg, J. E. (2018). How collegiate fraternity and sorority involvement relates to substance use during young adulthood and substance use disorders in early midlife: A national longitudinal study. The Journal of adolescent health : Official publication of the Society for Adolescent Medicine, 62(3 Suppl), S35. https://doi.org/10.1016/j.jadohealth.2017.09.029

24 Ibid. 

25 Rosenbloom, C. (2019, March 11). New Concern on College Campuses: ‘Drunkorexia,’ a Combination Drinking and Eating Disorder. The Washington Post. https://www.washingtonpost.com/lifestyle/wellness/new-concern-on-college-campuses-drunkorexia-a-combination-drinking-and-eating-disorder/2019/03/08/093cf47c-4028-11e9-9361-301ffb5bd5e6_story.html 

26 Ibid.

27 Wombacher, K., Matig, J. J., Sheff, S. E., & Scott, A. M. (2019). "It Just Kind of Happens": College Students' Rationalizations for Blackout Drinking. Health communication, 34(1), 1–10. https://doi.org/10.1080/10410236.2017.1384351 

28 Ehman, A. C., & Gross, A. M. (2019). Acceptance and Commitment Therapy and Motivational Interviewing in the Treatment of Alcohol Use Disorder in a College Woman: A Case Study. Clinical Case Studies, 18(1), 36–53. https://doi.org/10.1177/1534650118804886

The Hidden Social Struggles of Face Blindness

Navigating a Faceless World

“Being face blind means living in a world full of strangers…It’s actually a source of constant anxiety,” writes The Washington Post’s face-blind writer, Sadie Dingelder.[1] For people with prosopagnosia, or face blindness (a rare neurological disorder affecting nearly 3% of the population), social situations are complicated to navigate as the brain’s facial recognition system is flawed.[2] In humans, the face serves as a reminder for many memories of the identity of a person: such as their favorite food and their hobbies. When someone’s brain does not properly process this key component of social behavior, social anxiety quickly results. Prosopagnosia not only affects an individual's ability to recognize faces but also poses significant mental health challenges, impacting social interactions, self-esteem, and emotional well-being. 

Being face blind leads to an impairment in the ability to form identities, while other forms of identification (i.e., non-facial) are relied upon. Prosopagnosia tends to go relatively unnoticed not only because of its rarity but also because those who have it are skillful at working around their disability[3] or hiding it.  Additionally, recruitment for research on the subject becomes difficult, as those who have it may not always be aware if they have grown accustomed to having this deficit.[4] Additional research into prosopagnosia will provide vast opportunities to learn more about the social-cognitive disorders and mechanisms of the brain (such as autism spectrum disorder).

What is Face Blindness?

The main purposes of the brain’s visual facial recognition system revolve around sorting socially-meaningful information based on familiarity, attractiveness, and emotion.[5] Lopatina et al. (2018) note that face recognition impairment has been found to be associated with problems with neurons in the temporal lobe and/or the fusiform face area, particularly in the right middle fusiform gyrus.[6] Associations made with these areas are activated with other brain areas in forming/retrieving memories (the hippocampus) and emotion (the amygdala), establishing the interaction between facial recognition and social operation.[7] Essentially, visual information about faces cannot be translated into meaning. Additionally, face-selective neurons found in the amygdala support the notion that the brain uses facial recognition for emotionally salient, or meaningful stimuli.[8] The own-race bias of having better familiarity/encoding for faces of one’s own ethnicity rather than external ones can also be attributed to the brain’s facial recognition system.[9] When this system in the fusiform face area is impaired in individuals with prosopagnosia, so are the subsequent social processes. Prosopagnosia falls into two forms:[10]

1. Associative Prosopagnosia - One can perceive a face normally, but meaning cannot be applied. Even if the person is familiar, they can only be recognized in other ways (e.g., the sound of their voice, the way they walk).

2. Apperceptive Prosopagnosia - Faces are abnormally perceived and their facial expressions or other non-verbal cues cannot be recognized.

Causes for prosopagnosia can be related to genetic variants,[11] stroke, traumatic brain injury, tumors or some neurodegenerative diseases.[12] Prosopagnosia can often be found in individuals with autism (ASD) and Asperger’s Syndrome due to similar cognitive-emotional processes being affected.[13] Due to the similarity of brain areas and social behaviors affected by these neurological disorders, research targeting prosopagnosia has led to a multitude of information on the topic that augments our understanding of neural development and socially-debilitating disorders.

The Emotional Toll 

Davis et al. (2010) found that social anxiety (fears related to social rejection and social impressions) can stem from not only an inability to recognize facial expressions, but also from that of facial identity.[14] With impaired facial identification, those with prosopagnosia experience high social stress and anxiety in situations that critically involve communication, such as with family, at work and in public settings. The impairment can be so socially debilitating that it interferes with self-esteem and emotional well-being, resulting in difficulties in forming relationships and feelings of social isolation.[15] Having face blindness may also lead to avoidance of socially-engaging situations as a coping mechanism, which can even be considered a phobia in extreme cases.[16] Dalrymple et al. (2014) note that this deficit can begin early in life, as children who experience developmental prosopagnosia (DP) report discomfort and distress.[17] Guyer et al. (2010) add that emerging depression is also associated with facial memory deficits.[18] 

Coping Strategies and Treatment

Often, those with face blindness will develop coping strategies to alleviate daily challenges. Dalrymple et al. (2014) found that strategies to mitigate distress in children included asking a person’s name and remembering non-facial elements of a person’s appearance such as jewelry or hair.[19] Behavioral strategies like this are employed in face-blind-oriented training to facilitate the memory of people’s facial shapes and features.[20] These memory practices cannot cure prosopagnosia but can provide ways for individuals to adapt to social environments that require identification, thereby reducing social stress.[21] Lopatina et al. (2018) and Bate et al. (2014) also found that administering oxytocin (a hormone that facilitates human bonding)[22] can alleviate difficulties with social communication - some effectiveness was also noted in facilitating facial recognition in people with social behavioral deficits.[23,24] In addition, psychotherapeutic modalities such as cognitive behavioral therapy (CBT) may be utilized alone or in conjunction with anti-anxiety medication to mitigate the effects of social anxiety.[25]

This rare condition provides important insight into connections between the brain and social behavior. While the deficits in the brain associated with face blindness are not curable, an effort to develop identification strategies will help those with facial recognition difficulties in reducing high stress and anxiety when interacting with other people. 

If one feels as though they are experiencing symptoms of prosopagnosia (face blindness) or forms of social anxiety, 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 Dingfelder, S. (2019, August 21). My Life With Face Blindness. The Washington Post Magazine. https://www.washingtonpost.com/news/magazine/wp/2019/08/21/feature/my-life-with-face-blindness/ 

2 Ibid. 

3 Ibid. 

4. Ibid. 

5. Lopatina, O. L., Komleva, Y. K., Gorina, Y. V., Higashida, H., & Salmina, A. B. (2018). Neurobiological Aspects of Face Recognition: The Role of Oxytocin. Frontiers in Behavioral Neuroscience, 12, 399601. https://doi.org/10.3389/fnbeh.2018.00195 

6 Ibid. 

7 Ibid. 

8 Ibid. 

9 Blandón-Gitlin, I., Pezdek, K., Saldivar, S., & Steelman, E. (2014). Oxytocin eliminates the own-race bias in face recognition memory. Brain Research, 1580, 180-187. https://doi.org/10.1016/j.brainres.2013.07.015 

10 Cleveland Clinic. (2022, July 7). Prosopagnosia (Face Blindness). https://my.clevelandclinic.org/health/diseases/23412-prosopagnosia-face-blindness

11 Ibid. 

12 National Institute of Neurological Disorders and Stroke. (2023) Prosopagnosia. https://www.ninds.nih.gov/health-information/disorders/prosopagnosia#:~:text=What%20is%20prosopagnosia%3F,and%20%E2%80%9Clack%20of%20knowledge.%E2%80%9D

13 Ibid. 

14 Davis, J. M., McKone, E., Dennett, H., & Palermo, R. (2010). Individual Differences in the Ability to Recognise Facial Identity Are Associated with Social Anxiety. PLoS ONE, 6(12). https://doi.org/10.1371/journal.pone.0028800

15 Ibid. 

16 Davis et al. (2010)

17 Dalrymple, K. A., Fletcher, K., Corrow, S., S. Barton, J. J., Yonas, A., & Duchaine, B. (2014). “A room full of strangers every day”: The psychosocial impact of developmental prosopagnosia on children and their families. Journal of psychosomatic research, 77(2), 144. https://doi.org/10.1016/j.jpsychores.2014.06.001

18 E. Guyer, D. A., R. Choate, M. V., J. Grimm, D. K., S. Pine, D. D., & Keenan, D. K. (2011). Emerging depression is associated with face memory deficits in adolescent girls. Journal of the American Academy of Child and Adolescent Psychiatry, 50(2), 180. https://doi.org/10.1016/j.jaac.2010.11.008

19 Dalrymple et al. (2014)

20 Cleveland Clinic

21 Ibid.

22 Jones, C., Barrera, I., Brothers, S., Ring, R., & Wahlestedt, C. (2017). Oxytocin and social functioning. Dialogues in clinical neuroscience, 19(2), 193–201. https://doi.org/10.31887/DCNS.2017.19.2/cjones 

23 Lopatina et al. (2018)

24 Bate, S., Cook, S. J., Duchaine, B., Tree, J. J., Burns, E. J., & Hodgson, T. L. (2014). Intranasal inhalation of oxytocin improves face processing in developmental prosopagnosia. Cortex, 50, 55-63. https://doi.org/10.1016/j.cortex.2013.08.006 

25 Johns Hopkins Medicine. (n.d.) Phobias. www.hopkinsmedicine.org/health/conditions-and-diseases/phobias